This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.
Here are some of the biggest changes in quality reporting.
Attention small practices: You can no longer avoid the penalty with minimal reporting. Last year the performance threshold was a MIPS final score of 45 points. This meant that if you were in a small practice, and you were excluded from the cost and promoting interoperability performance categories, you could avoid the payment penalty by maxing out your 2020 improvement activities score and then doing minimal quality reporting—as little as reporting six measures just one time for just one patient.
That won’t work in 2021. Now that you need a MIPS final score of 60 points to avoid the payment penalty, your quality score will need to be much higher. In 2021, because many claims-based measures are subject to extreme scoring limitations, it will be very difficult to avoid a payment penalty if you are reporting quality measures by claims. Indeed, if you don’t have an electronic health record (EHR) system, avoiding a penalty will be difficult even if you use the IRIS Registry, though you can still try to minimize that penalty.
Eight IRIS Registry measures now have benchmarks. As a qualified clinical data registry (QCDR), the IRIS Registry can develop its own QCDR measures. It has developed 30 of these IRIS measures, eight of which now have benchmarks, up from five last year. These ophthalmology-specific measures can be reported only via the IRIS Registry. If you previously used claims to report quality measures, you may find that these QCDR measures provide a more feasible pathway to avoiding or minimizing the penalty.
Change to hospital readmission measure. The All-Cause Hospital Readmission (ACR) measure has been replaced with quality measure 479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the MIPS Eligible Clinician Groups. Few ophthalmologists are likely to meet the case minimum for the HWR measure.
Measure 12: Primary Open Angle (POAG): Optic Nerve Evaluation now only available for EHR-based reporting. You can no longer report measure 12 manually via the IRIS Registry or via claims. You can still report it via IRIS Registry–EHR integration, but you should check the changes to its measure specifications.
Measure 419: Overuse of Imaging for the Evaluation of Primary Headache can no longer be reported by claims. The measure can still be reported manually via the IRIS Registry.
Double-check the measure specifications. Whichever quality measures you plan to report—even if you reported them last year—you should check the measure specifications to make sure you understand how the measures are performed, how your performance rate will be determined, and what documentation you should maintain.
If you plan to report MIPS via the IRIS Registry, you can log in to it and download PDFs of the measure specifications. You also download these PDFs from the 2021 Clinical Quality Measure Specification and Benchmark Table at aao.org/medicare/quality-reporting-measures.
The following quality measures, for example, have undergone substantive changes to their specifications for at least one collection type (quality measures can have different specifications depending on which reporting mechanism you use):
- Measure 1: Diabetes: Hemoglobin A1c Poor Control
- Measure 12: POAG: Optic Nerve Evaluation
- Measure 14: AMD: Dilated Macular Examination
- Measure 19: Diabetic Retinopathy: Communication With the Physician Managing Ongoing Diabetes Care
- Measure 110: Preventive Care and Screening: Influenza Immunization
- Measure 117: Diabetes: Eye Exam
- Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
- Measure 130: Documentation of Current Medications in Medical Record
- Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Measure 236: Controlling High Blood Pressure
- Measure 238: Use of High-Risk Medications in Older Adults (previously known as Use of High-Risk Medications in the Elderly)
- Measure 265: Biopsy: Follow-Up
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