This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.
For the Public Health and Clinical Data Exchange objective, you must report your performance rate—or claim an exclusion—for these two measures:
- Immunization Registry Reporting
- Electronic Case Reporting
You also can earn 5 bonus points by reporting any of the three optional measures:
- Public Health Registry Reporting
- Clinical Data Registry Reporting (e.g., IRIS Registry)
- Syndromic Surveillance Reporting
Note: You are eligible for this bonus even if you claim exclusions for both the Immunization Registry Reporting measure and the Electronic Case Reporting measure. You get the same number of bonus points (5) whether you report one, two, or three of the optional measures.
New for 2023: A revised definition of active engagement. All five measures in this objective involve your active engagement in reporting to either a registry or a public health agency (PHA). For the 2023 performance year, you have two options for demonstrating active engagement:
1) preproduction and validation or
2) validated data production
(Previously there were three options: 1) completing a registration to submit data, 2) testing and validating the electronic submission of data, and 3) electronically submitting production data.)
New for 2023: Report your level of engagement. When you report that you met the requirements for any of the five measures in this objective, you must now also attest to your level of engagement (either validated data production or preproduction and validation).
What if you are reporting as a group? If your practice is reporting MIPS as a group, CMS has said that you should select the level of engagement that “best reflects the composition of the group (for example, the level that reflects the status of the majority of the MIPS eligible clinicians in the group.)” The agency also has said that your group can attest “yes” for this objective’s two required measures if one MIPS eligible clinician meets the measures’ requirements.
New for next year: A timetable for full engagement. Starting with the 2024 performance year, you will only be able to report the preproduction and validation level of engagement for a measure once before moving on to the validated data production level the next time you report that measure. This assumes that you are involved with the same registry or PHA in both years; if you switch to a different organization, you will be able to spend an additional year in preproduction and validation. (Note: CMS has said that it won’t take into account your level of engagement for 2023. If you are in preproduction and validation in 2023, you will be able to stay at that level of engagement in 2024 before being obligated to move to validated data production in 2025.)
Exclusions. Exclusions are available for the two required measures, but not for the three optional measures.
Exclusion for the Immunization Registry Reporting measure. You can qualify for an exclusion if one or more of these three criteria applies:
- “Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the performance period.”
- “Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.”
- “Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of six months prior to the start of the performance period.”
Exclusion for the Electronic Case Reporting measure. You can qualify for an exclusion if one or more of these three criteria applies:
- “Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the performance period.”
- “Operates in a jurisdiction for which no PHA is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.”
- “Operates in a jurisdiction where no PHA has declared readiness to receive electronic case reporting data as of six months prior to the start of the performance period.”
If you claim exclusions for both of this objective’s required measures, the points associated with them would be redistributed to the Provider to Patient Exchange objective.
Previous: PI: The Provider to Patient Exchange Objective
Next: PI: How You'll Be Scored
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