This content is excerpted from EyeNet’s MIPS 2021; 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, one of which requires an EHR system.
In a small practice? Now that the MIPS performance threshold is 60 points, avoiding a penalty will involve reporting much more quality data than in the past, and this will be especially onerous if you aren’t reporting via EHR..
Which reporting option(s) should you pick? CMS may score a measure differently depending on which collection type was used. You should note that many quality measures subject to significant scoring limitations when reported via claims, which means that it will be difficult to avoid the penalty with claims-based reporting.
Start by reading about option 1 (via IRIS Registry–ER integration), option 2 (manually via the IRIS Registry), and option 3 (via claims), below, and then see which quality measures are available for each reporting option, and see whether those measures are subject to significant scoring limitations:
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 your EHR system. Furthermore, you only can use integrated reporting if your EHR system is a 2015-edition or a 2015-edition Cures Update certified EHR technology (CEHRT). To find out which CEHRTs have been integrated with the IRIS Registry, visit aao.org/iris-registry/ehr-systems.
Select which quality measures you want to report. You should report at least six measures, but can report more than that. The Academy urges you to include all the IRIS Registry–developed measures that you have data for. The more data CMS gets on these measures, the more likely they are to acquire MIPS benchmarks.
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 EHR system are being transferred over to the IRIS Registry correctly. If you suspect a problem, you can work with staff from the IRIS Registry vendor (FIGmd) 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 2021 reporting, you need to meet both the June 1 sign-up deadline and the Aug. 1 integration deadline.
Option 2: Report Quality Measures Manually via the IRIS Registry
Each year, hundreds of practices have entered their MIPS quality data manually via the IRIS Registry. Some of them have no EHR system; others have one but haven’t integrated it with the IRIS Registry.
Choose from 55 quality measures. These 55 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 quality data at the individual-clinician level. In January 2022, when you are getting ready to hit the “submit” button that sends your data to CMS, you can opt to report as an individual or as part of a group.
Start entering quality data ASAP. If you enter data for quality measures as promptly as possible after each relevant patient encounter, you can identify areas of underperformance while you still have time to do something about it.
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.
The IRIS Registry Developed Its Own Ophthalmology-Specific Quality Measures
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., IRIS1).
Up to 30 ophthalmology-specific quality measures for IRIS Registry users. 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 eight QCDR measures. There are already benchmarks for IRIS1, IRIS6, IRIS13, IRIS23, IRIS43, IRIS44, IRIS48, and IRIS50. After the 2021 performance year is over, CMS will see if there is enough 2021 performance data to retroactively create reliable benchmarks for the other 22 QCDR measures.
Option 3: Report Quality Measures via Medicare Part B Claims
Table: Reporting Quality Measures via Medicare Part B Claims lists the 13 claims-based measures that are most relevant to ophthalmology. Scoring for many claims-based measures “stalls” at a low decile. (To explore all the claims-based measures, go to https://qpp.cms.gov/mips/explore-measures/quality-measures.)
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 aao.org/medicare/claims-reporting-guide.
You Can Report via Multiple Collection Types
You can, for example, 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 you reported via the IRIS Registry and one measure that you 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 your EHR vendor. Some EHR vendors may offer a reporting option, though they won't include any of the IRIS Registry's 30 QCDR measures.
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.
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 can 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 2023.
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, 2019, and Sept. 30, 2020.
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.
Meet These IRIS Registry Deadlines
If you want to start reporting MIPS quality measures via IRIS Registry–EHR integration:
- Sign up for integration by June 1. (If you started, but didn’t complete, the integration process last year, June 1 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, 2022.
- Press the “Submit” button to send data to CMS by Jan. 31, 2022.
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, email irisregistry@aaoorg. If you have more technical questions—relating, for example, to quality data mapping issues—you can submit a help desk ticket.
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All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).