This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.
It is now much harder for clinicians to avoid the MIPS payment penalty, and this is especially true if you are in a small practice without an electronic health record (EHR) system.
Small practices without EHR might be able to get a MIPS final score of more than 15 points, and thus avoid the maximum penalty of –9%. However, avoiding a penalty altogether will be a big challenge. The reasons include the following:
Performance threshold raised to 60 points. To avoid a future payment penalty, your MIPS final score must meet or exceed the year’s performance threshold. This year’s performance threshold is 60 points, up from 45 points last year (see Table: Bonuses and Penalties). Small practices without an EHR system are likely to feel the greatest negative impact. Previously, such practices could avoid the penalty by submitting minimal data on six quality measures and also maxing out their score for the improvement activities performance category. While small practices will still earn 3 achievement points toward their quality score for doing minimal reporting on a measure (e.g., reporting the measure one time on one patient), the new performance threshold means that they need to do more than that to avoid the payment penalty.
What does it take to earn more than 3 achievement points for a quality measure? Like last year, to earn more than 3 points for a quality measure, small practices must meet the two data submission thresholds—reporting on 1) at least 20 patients and 2) at least 70% of denominator-eligible patients. This will be less onerous for practices that have an EHR system and have integrated it with the IRIS Registry. If you are reporting manually via the IRIS Registry, you will also have to track your data-completeness totals.
Claims-based quality measures must be reported in real time. Small practices—but not large practices—can still report quality measures via claims. However, if you are reporting via claims, you do your reporting throughout the year when you submit your requests for payments. This means that you will probably need to start reporting early in the year if you want to report on 70% of denominator-eligible patients, which is a prerequisite for earning more than 3 achievement points for a measure (see above).
Significant scoring limitations for quality measures that are reported via claims. When a quality measure isn’t subject to any scoring limitations, you can earn up to 10 achievement points for it. But this year, many of the measures most relevant to ophthalmology are subject to score “stalling” and, in some cases, a 7-point cap when reported via claims. For example, even if you have an extremely high performance rate of 99.99% for measure 14 (a retina measure) or measure 141 (a glaucoma measure), you would only earn 3.9 achievement points for each of them; a performance rate of 100% would earn you 7 points for measure 14 and 10 points for measure 141.
Measure 12—optic nerve evaluation in cases of primary open-angle glaucoma—can only be reported via EHR. Measure 12 can no longer be reported manually via the IRIS Registry or via claims. This is because its benchmarks for those two reporting mechanisms had been “topped out” for three consecutive years.
Avoiding the Penalty
If you are in a small practice without an EHR system, one route to attaining a MIPS final score of at least 60 points, and thus avoiding the penalty, would be as follows:
- Max out your score for the improvement activities performance category, which would then contribute 15 points to your MIPS final score.
- Be approved for a promoting interoperability (PI) hardship exception, which would mean PI’s weight in your MIPS final score would be reassigned to quality (increasing quality’s weight from 40% of your MIPS final score to 65%; see Table: How the Performance Categories Are Weighted).
- Meet the two data submission thresholds for at least six quality measures.
- Given that you don’t know what your score will be for the cost performance category, you should aim to score an average of 6.02 points for each quality measure. This—together with the 6-point small practice bonus for reporting quality —will give you a quality score of 70.20%. If quality is weighted at 65% of your MIPS final score, then a quality score of 70.20% will contribute 45.63 points (70.20% of 65 points) to your MIPS final score. Along with your 15 points for maxing out the improvement activities performance category, plus a possible complex patient bonus, you will score high enough to avoid the penalty.
- If you don’t perform cataract surgery, then you may be excluded from the cost performance category. If you are excluded from both cost and promoting interoperability, quality’s weight in your MIPS final score would be 85% (see Table: How the Performance Categories Are Weighted), and you would now need an average of 4.6 points for each of six quality measures, along with a 100% score for improvement activities to avoid the payment penalty.
Bottom line. Given the scoring limitations for many quality measures, particularly those reported by claims, it will be difficult for small practices without EHR systems to avoid the payment penalty.
However, their MIPS reporting can reduce the penalty and mitigate its impact on reimbursement in 2023. By attaining a MIPS final score of more than 15 points, they can avoid the maximum –9% penalty, and the closer they get to 60 points the smaller their penalty will be (see Table: Payment Penalty).
Interested in adopting an EHR system? EHR technology can provide multiple benefits for streamlined workflow and documentation, as well as for electronically reporting quality for MIPS. For more on EHRs, visit aao.org/practice-management/electronic-health-records/ehrs.
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