• MIPS 2021—PI: What You Need to Do

    This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.


    Understand PI’s Structure

    Promoting interoperability (PI) is arranged around four objectives: 

    1. e-Prescribing;
    2. Health Information Exchange;
    3. Provider to Patient Exchange; and
    4. Public Health and Clinical Data Exchange.

    Each objective has at least one measure associated with it (see Table: Promoting Interoperability at a Glance).

    Fall short with even just one measure and your PI score will be 0%. In order to earn any score for the PI performance category, you must either 1) report or, if an exclusion is available, 2) claim an exclusion for all the required measures. If you fail to do that, your PI score will be 0% and will contribute 0 points to your MIPS final score. (Note: When you report a numerator, it must be at least 1.)

    You may be able to claim exclusions for some measures. Exclusions are available for most of the PI measures (see Table: Promoting Interoperability Exclusions at a Glance). For example, there is an exclusion available for the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure. If you qualify for and claim that exclusion, the 20 points available for that measure would be reallocated to another measure.

    Not all PI measures have exclusions. There is no exclusion for the Provide Patients Electronic Access to Their Health Information measure, which CMS has described as “the crux” of the PI performance category.

    The e-Prescribing objective’s opioid-related bonus measure is optional in 2021, and therefore doesn’t need an exclusion.

    There also is no exclusion for the new HIE Bi-Directional Exchange measure, but you can opt to report the two Support Electronic Referral Loops measures instead.

    The Performance Period for PI Is At Least 90 Days

    Pick a performance period of at least 90 continuous days and no more than the calendar year. 

    Pick your date range. You must use the same performance period—i.e., same start date and same end date—for each of the scored PI measures that you report. 

    The Security Risk Analysis can be done on a separate schedule. The unscored Security Risk Analysis measure doesn’t have to be done during the performance period that you are using for the scored PI measures. It can be performed at any time during the 2021 calendar year. However, it must be an analysis of the same 2015-edition or 2015-edition Cures Update CEHRT that is being used to perform the scored measures.

    Last day to start performing PI measures is Oct. 3. Don’t wait till October; make sure you allow yourself some leeway in case you run into any problems.

    What you should be doing early in the year. Make sure you understand the PI measures and know what you need to do to meet their requirements. Read the measure descriptions and documentation suggestions at aao.org/medicare/promoting-interoperability/measures). Your EHR system should allow you to run PI reports; run them to see what your performance rates are. If performance rates seem low, try to pinpoint the source of the problem—are data being entered into the right fields? Do you need to make changes to workflow? If any physicians joined your practice this year, make sure they are included in the reports.

    Document measure performance. Make sure your documentation includes dates, so you can show that you met the performance period requirements. You won’t need to provide this when you report your PI measures, but you should keep it for six years in case you are audited. 

    Three Critical Attestations

    You must submit “yes” for these three attestations. Failure to do so will result in a PI score of 0%. 

    Submit “yes” to attest that you performed the Security Risk Analysis. The security risk analysis:

    • must be documented (in case of an audit),
    • must be done at some point during the 2021 performance year, and
    • must involve an analysis of the CEHRT that you have in place during your 90-day PI performance period.

    However, it doesn’t have to take place during that 90-day performance period. This Security Risk Analysis is also a requirement of the HIPAA Security Rule.

    Submit “yes” for the Prevention of Information Blocking attestation. Attest “yes” to three statements about how you have implemented and used your EHR system. This requirement reflects a CMS concern that practices might “knowingly and willfully” take action to limit and restrict the compatibility or interoperability of CEHRT.

    Submit “yes” for the ONC Direct Review attestation. The ONC—otherwise known as the Office of National Coordinator for Health Information Technology—is responsible for certifying EHR systems as CEHRTs, and for monitoring CEHRTs to make sure they continue to meet their certification requirements. Occasionally, ONC may need to conduct a “direct review” of a vendor’s EHR product (for example, if ONC has a reasonable belief that faults within the EHR system may present a risk to public health). By submitting “yes” to this attestation, you agree to cooperate with ONC in such a review.

    Reporting PI as a Group?

    If the MIPS eligible clinicians in your practice are reporting a performance category as a group, they must aggregate their performance data across the group’s Tax Identification Number (TIN). However, for the PI performance category, you would only use the performance data of those clinicians for whom you have data in a CEHRT.

    Previous: PI: Your EHR System Must Be a CEHRT

    Next: PI: How You’ll Be Scored 

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