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  • MIPS 2022—What’s New With Quality

    Excerpted from “MIPS—What’s New for 2022, Part 1: Scoring, Bonuses, and Penalties” (EyeNet, January 2022). Also see, EyeNet’s MIPS Manual 2022: A Primer and Reference.

    As in previous years, you can earn achievement points for reporting a quality measure. Your score for a measure will depend on how your performance rate compares against the measure’s benchmark. CMS used 2020 performance data to establish 2022 benchmarks for quality measures, and the agency published those benchmarks in late December. 

    No more high priority or CEHRT bonus points. Some quality measures are flagged as high priority measures. During the first five years of MIPS, CMS encouraged clinicians to report these measures by awarding high priority bonus points. CMS also sought to encourage use of electronic health records (EHRs) by awarding bonus points for “end-to-end electronic reporting” of quality measures via a certified EHR technology (CEHRT). Starting in 2022, you can no longer earn high priority bonus points or end-to-end CEHRT bonus points.

    The CMS rationale for eliminating high priority and CEHRT bonus points. CMS has said that it plans to move away from “traditional MIPS” to MIPS value pathways (MVPs). Each MVP will include a limited number of measures and activities from all four MIPS performance categories—quality, pro­moting interoperability, improvement activities, and cost. Under the MVP framework, CMS believes that it won’t need bonus points to encourage the reporting of high priority measures or the use of CEHRT. However, CMS has only developed seven MVPs so far, none of which are relevant to ophthalmology. Furthermore, the launch of MVPs as an option alongside traditional MIPS reporting has been pushed back to the 2023 performance year. (Note: The quality performance category still re­tains the 6-point small practice bonus.)

    CMS is adding an incentive for reporting new quality measures. If you report a new quality measure, and your reporting meets the data completeness requirement, CMS says that you would earn:

    • at least 7 achievement points if 2022 is the measure’s first year in the MIPS program, and
    • at least 5 achievement points if 2022 is the measure’s second year.

    What is the data completeness re­quirement? As in 2021, you would need to report on at least 70% of patients you saw who were eligible for the mea­sure’s denominator.

    CMS removed some quality mea­sures. CMS removed some quality measures for at least some reporting options. Those that are most relevant to ophthalmologists are discussed below.

    Measure 14: AMD: Dilated Macular Examination can no longer be reported via claims. For two successive years, Measure 14’s benchmark for claims-based reporting was “topped out,” which is the term that CMS uses when performance rates are so good that there is limited opportunity for improvement. CMS has said that if a quality measure’s benchmark for a particular reporting mechanism (e.g., claims-based report­ing) is topped out for two successive years, it will typically rule that the measure can no longer be reported via that mechanism. (Note: Measure 14 can still be reported manually through the IRIS Registry or via IRIS Registry–EHR integrated reporting. Those reporting options have their own benchmarks.)

    Other measures that can no longer be re­ported. The measures below were topped out for two successive years and can no longer be reported by any reporting mechanism:

    • IRIS5: Surgery for Acquired Involu­tional Ptosis: Patients With an Im­provement of Marginal Reflex Distance (MRD)
    • IRIS26: Avoidance of Routine Anti­biotic Use Before or After Intravitreal Injection
    • IRIS45: Exudative AMD: Loss of Visual Acuity
    • IRIS52: Postoperative Opioid Man­agement Following Ocular Surgery
    • Measure 154: Falls: Risk Assessment

    Tip: Although Measure 154 has been removed, you can still use IRIS Registry–EHR integrated reporting to report another falls-related measure, Measure 318: Falls: Screening for Future Falls Risk.

    CMS made changes to several qual­ity measures. Each year, when planning which quality measures to report, you should check the measures’ specifica­tions to make sure that you understand them and so that you can alert staff and physicians to any changes in the specifications. Of the measures that are most relevant to ophthalmology, those that have undergone changes include the following:

    • Measure 1: Diabetes: Hemoglobin A1c Poor Control (>9%)
    • Measure 110: Preventive Care and Screening: Influenza Immunization
    • Measure 111: Pneumococcal Vacci­nation Status for Older Adults
    • Measure 117: Diabetes: Eye Exam
    • 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
    • Measure 265: Biopsy Follow-Up
    • Measure 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
    • Measure 318: Falls: Screening for Future Falls Risk
    • Measure 374: Closing the Referral Loop
    • Measure 397: Melanoma Reporting
    • IRIS55: Visual Acuity Improvement Following Cataract Surgery and Mini­mally Invasive Glaucoma Surgery
    • IRIS59: Regaining Vision After Cata­ract Surgery

    A new administrative claims–based quality measure based on hospital admission rates for patients with multiple chronic conditions. CMS has added a new quality measure that is based on Medicare administrative claims data and thus doesn’t involve any reporting by a practice or clinicians. The measure is based on hospital admission rates for patients with multiple chronic condi­tions. Ophthalmology practices are unlikely to meet the case minimum for this measure.

    Previous: MIPS 2022—Small Practices: New Policies for Reweighting Promoting Interoperability

    Next: MIPS 2022—What’s New With Promoting Interoperability 

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