• MIPS 2020—Quality: Pick Your Collection Type

    This content is excerpted from EyeNet’s MIPS 2020; also see the Academy’s MIPS hub page.


    Your MIPS reporting options—or collection types, as CMS calls them—will depend, in part, on whether you have an electronic health record (EHR) system. For example, the IRIS Registry offers two reporting options: Integrated reporting, which requires an EHR system, and manual reporting via the IRIS Registry, which doesn’t. Claims-based reporting is another option that doesn’t require EHR.

    Which reporting option(s) should you pick? CMS may score a measure differently depending on which collection type was used, with many quality measures subject to significant scoring limitations when reported via claims. After reading about the options 1, 2, and 3 below, see which quality measures are available for each reporting option, and to see whether those measures are subject to significant scoring limitations:

    Up to 30 ophthalmology-specific quality measures for IRIS Registry users. As a qualified clinical data registry (QCDR), the IRIS Registry has been able to develop its own quality measures. These measures have an “IRIS” prefix (e.g., IRIS 2: Intraocular Pressure Reduction). You can report on any of the 30 QCDR measures manually, but the measures available for integrated IRIS Registry–EHR reporting may depend on what data can be extracted from your EHR system.

    Benchmarks available for six QCDR measures. There are already benchmarks for IRIS1, IRIS2, IRIS13, IRIS17, IRIS23, and IRIS26. After the 2020 performance year is over, CMS will see if there is enough 2020 performance data to retroactively create reliable benchmarks for the other 24 IRIS measures.

    Option 1: Report Quality Measures via IRIS Registry–EHR Integration

    The most efficient way to report quality measures is to integrate your EHR system with the IRIS Registry. Once you have done that, an automated process can extract MIPS quality data from your EHRs.

    The quality measures available to you may depend on your EHR. Up to 43 quality measures are available to report via IRIS Registry–EHR integration, including 30 ophthal­mic measures that were developed specifically for the IRIS Registry. However, you can only report a measure if the IRIS Registry is able to extract the relevant data elements from your EHR system—so the quality measures that are available to you may depend on which EHR system you are using. Furthermore, you only can use integrated reporting if your EHR system has been certified as a 2015-edition certified EHR technology (CEHRT). To find out which 2015-editon CEHRTs have been integrated with the IRIS Registry, visit aao.org/iris-registry/ehr-systems.

    Automated reporting. After the performance year is over, an IRIS Registry algorithm will select the measures taht will maximize your score. (Note: This automated process is only applied to quality measures; you must man­ually report promoting interoperability measures and improvement activities.)

    Report on all relevant patients. For each mea­sure that you report, include both Medicare and non-Medicare patients.

    Start checking your quality data. You should make sure that data from your EHRs are being transferred over to the IRIS Registry correctly. If you suspect a problem, you can work with IRIS Registry staff to make any necessary adjustments. Also be on the lookout for workflow problems. For example, is information being entered into the EHR correctly? The earlier in the year you address such problems, the less likely they are to impact your MIPS reporting.

    Not yet integrated? If you want to start inte­grating your EHR system with the IRIS Registry for 2020 reporting, you need to meet both the June 19 and Aug. 1 deadlines. (See “Meet These IRIS Registry Deadlines.”)

    Option 2: Report Quality Measures Manually via the IRIS Registry

    Each year, hundreds of ophthalmology practices avoid a future MIPS penalty by entering quality measure data into the IRIS Registry. Some of them have no EHR system; others have one but haven’t integrated it with the IRIS Registry.

    Choose from 56 quality measures. These 56 measures include 30 ophthalmology-specific ones that were developed by the IRIS Registry.

    Report on all relevant patients. If you report a measure manually via the IRIS Registry, you should do so on both Medicare and non-Medicare patients.

    Enter quality data at the individual-clinician level. Throughout the year, enter data for quality measures at the in­dividual-clinician level. In January 2021, when you are getting ready to hit the “submit” button that sends your data to CMS, stipulate whether you are reporting as a group or as a group.

    Start entering quality data ASAP. The Academy urges you to enter data for quality measures as promptly as possible after each relevant patient encounter. This will help you to identify areas of underperformance while you still have time to do something about it, and will also avert the stress of the last-minute rush.

    Track the data completeness totals. For each measure that you report, you also need to report the total number of patients eligible for the measure and, if the measure definition includes exceptions, the total number of patients excepted. Contact the vendor of your billing system to see if they can provide instructions on running the appropriate reports.

    Option 3: Report Quality Measures via Medicare Part B Claims

    Table: Reporting Quality Measures Via Medicare Part B Claims lists the 15 claims-based measures that are most relevant to ophthalmology. Note that scoring for many claims-based measures “stalls” at a low decile. (If you want to explore all the claims-based measures at the QPP web site: Go to https://qpp.cms.gov; make sure you pick “2020” as the performance year and “Medicare Part B claims measures” as the collection type).

    You must be in a small practice. Clinicians in large prac­tices can’t report via claims; clinicians in small practices can do so—and can do so whether reporting as a group or as individuals. To learn how CMS determines practice size, see “Small or Large Practice?

    What do you report? You only report on Medicare Part B patients and—unlike manual reporting via the IRIS Registry —you don’t need to report on the data completeness totals.

    When do you report? Report measures in real time using the CMS 1500 form. For detailed instructions, see the Academy’s Claims Reporting Guide.  

    You Can Report via Multiple Collection Types

    You can report via more than one collection type. For example, you can report two measures via claims and four different measures via the IRIS Registry.

    But suppose you report six measures by Medicare Part B claims and you also report the same six measures manually via the IRIS Registry. For each measure, CMS will calculate scores for both collection types and then assign you the higher of those two scores—so your final quality score could, for ex­ample, be based on five measures that were reported via the IRIS Registry and one measure reported via claims.

    What if you switch collection types? Suppose, for exam­ple, you report a measure via claims from January through June and then switch to reporting it manually via the IRIS Registry from July through December. CMS will not aggre­gate your data from both collection types. It will score you separately for each collection type.

    Note: When you report via more than one collection type, you must use the same identifier each time (see “Use of TINs and NPIs as Identifiers”).

    Other Reporting Options

    Via EHR. Some EHR vendors may offer a reporting option.

    Consider reporting quality at the group level. There are some advantages to reporting as a group. Suppose, for example, a practice consists of four cataract subspecialists and a pediatric ophthalmologist. The latter might find it a challenge to report on six quality measures, but doing so wouldn’t be a problem for the group as a whole. (See “Partic­ipate as an Individual or as a Group?”).

    If you’re in an accountable care organization (ACO), you should still report MIPS quality measures in case your ACO’s reporting is unsuccessful. If the ACO is successful in its MIPS reporting, CMS will ignore the quality measures that you reported. But if your ACO is unsuccessful in its MIPS reporting, your independent quality reporting can safeguard you from the –9 % payment adjustment in 2022.

    Facility-based scoring isn’t an option for most ophthal­mologists. Facility-based scoring will only be available to you if you provide at least 75% of your covered professional services at an inpatient hospital (place of service [POS] code: 21), an on-campus outpatient hospital (POS code: 22), or an emergency room (POS code: 23), with at least one service at an inpatient hospital or emergency room. This is based on claims submitted between Oct. 1, 2018, and Sept. 30, 2019.

    What if you are eligible for facility-based scoring but you also do your own MIPS reporting? CMS will assign you the facility’s score for quality and cost unless your separate MIPS submission earns you a higher combined score for those two performance categories.

    What is the CMS Web Interface? The CMS Web Interface is used by some big practices that provide primary care services. It is a reporting option for the quality performance category. It has its own reporting requirements, its own set of quality measures (mostly pri­mary care–based), and a 12-month performance period. It replaced the PQRS program’s Group Practice Reporting Option (GPRO) web interface and is only available to practices that have at least 25 eligible clinicians reporting quality data.

    Meet These IRIS Registry Deadlines

    If you want to start reporting MIPS quality measures via IRIS Reg­istry–EHR integration:

    • Because of the COVID-19 crisis, the deadline to sign up for integration has been extended from June 1 to June 19. If you started, but didn’t com­plete, the integration process last year, June 19 is also the deadline for notifying FigMD that you want to complete integration this year. 
    • Complete the integration process by Aug. 1.
    • E-sign a data release consent form by Jan. 31, 2021.
    • Press the “Submit” button to send data to CMS by Jan. 31, 2021.

    If you want to manually report MIPS via the IRIS Registry:

    Got questions? Start with the IRIS Registry user guide. If that doesn't answer any questions about navigating the IRIS Registry screens, contact Academy customer service staff at cus­tomer_service@aao.org or 415-561-8540.

    If you have more technical questions—relating, for example, to quality data mapping issues, ob­taining your IRIS Registry log in credentials, or changing your IRIS Registry practice information—contact irisregistry@aao.org.

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