This content is excerpted from EyeNet’s MIPS 2020; also see the Academy’s MIPS hub page.
For some PI measures, scoring is based on your performance rate. You can, for example, score up to 10 points for the e-Prescribing measure; if your performance rate is 82%, you would score 8 points. (Note: In calculating this point score, CMS typically rounds off to the nearest whole number. The exception is when the nearest whole number is 0 points; provided you have reported on at least one patient, CMS will round up to 1 point.)
Your performance rate is based on a numerator and a denominator. For the e-Prescribing measure, to continue the example, the denominator is the number of prescriptions written during the performance period for drugs that require prescriptions; and the numerator is the number of those prescriptions that were 1) generated, 2) queried for a drug formulary, and 3) transmitted electronically using a certified EHR. You need a numerator of at least 1 to successfully report the measure. (For information on the numerators and denominators of the performance rate–based measures, see the detailed measure descriptions.)
Exceptions: Scoring is not performance rate–based for the Public Health and Clinical Data Exchange measures. For the five measures that involve reporting to registries or public health agencies, you attest “yes” or “no” to indicate whether you are actively engaged with registries or public health agencies. Scoring for this objective is on a pass/fail basis, with 10 points for a pass and 0 points for a fail.
To pass, either 1) provide two “yes” responses or 2) provide one “yes” response and claim one exclusion. If you provide no “yes” responses but claim two exclusions, the 10 points will be reallocated to the Provider to Patient Exchange objective. Note: To be actively engaged with a registry or agency, you must be either sending production data to the entity or in the process of moving toward doing so. (For a more complete definition of active engagement, see the measure descriptions.)
Exception: Scoring is not performance-rate based for the Query of Prescription Drug Monitoring Program (PDMP) bonus measure. CMS had initially designed this as a performance-rate based measure, but a lack of EHR-PDMP integration meant that clinicians would have to track their numerator and denominator manually or develop custom reports. Consequently, CMS changed this to a measure that requires a “yes” or “no” attestation. Attesting “yes” indicates that “for at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician then used data from CEHRT to conduct a query ofa PDMP for prescription drug history, except where prohibited and in accordance with applicable law.” CMS has asked the ONC to see how the CEHRT program can support PDMP-EHR integration in the future.
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