This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.
For the quality performance category, 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.
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 are subject to significant scoring limitations when reported via claims, which means that it will be more difficult to avoid the penalty with claims-based reporting.
Start by reading about option 1 (reporting via IRIS Registry–EHR 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. This year, for most practices, this integration process is being transitioned from FIGmd to Verana Health..
The quality measures available to you may depend on your EHR. Dozens of measures are available to report via IRIS Registry–EHR integration, including 26 ophthalmic measures that were developed specifically for the IRIS Registry. However, you can report a measure only if the IRIS Registry is able to extract the relevant data elements from your EHR system. Thus, the quality measures that are available to you may depend on your EHR system. Furthermore, you can use integrated reporting only if your EHR system is a 2015-edition Cures Update certified EHR technology (CEHRT). To find out which CEHRTs can be used for IRIS Registry–EHR integrated reporting in 2023, visit aao.org/iris-registry/ehr-systems.
Select your quality measures. You should report at least six measures, but can report more than that. Include an outcome measure. The Academy urges you to include all the IRIS Registry–developed measures that you have data for. This will increase the likelihood that CMS can establish MIPS benchmarks for those measures.
Report on all relevant patients. For each measure that you report, include both Medicare and non-Medicare patients.
Start checking your quality data. Make sure that data from your EHR system are being transferred over to the IRIS Registry correctly.
Be on the lookout for workflow problems. For example, is information being entered into the EHR correctly? Spot such problems early to reduce their impact on your MIPS reporting.
Used this reporting option in 2022 but are now changing to a new EHR system? Notify the IRIS Registry vendor no later than June 15 if there have been significant changes, such as a systems upgrade, a move to a cloud-based system, or a move to another system. If you delay, you might not be able to complete data mapping in time for 2023 reporting.
Not yet integrated? If you want to start integrating your EHR system with the IRIS Registry for 2023 reporting, you need to meet both the June 15 sign-up deadline and the Aug. 1 integration deadline.
Option 2: Last Year to Report Quality Measures Manually via the IRIS Registry
Use this option if you don't use EHRs, or if you have an EHR system that isn't integrated with the IRIS Registry.
Choose from 50 quality measures. These measures include 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.
Throughout the year, enter quality data at the individual-clinician level. It won't be until January 2024, when you are getting ready to hit the “submit” button that sends your data to CMS, that you decide whether to report as an individual or as part of a group.
Start entering quality data ASAP. If you enter data for quality measures regularly throughout the year, 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.
2023 is the last year for manual reporting. The Academy and its IRIS Registry partner, Verana Health, will discontinue the IRIS Registry's manual web reporting tool after the 2023 performance year.
Option 3: Report Quality Measures via Medicare Part B Claims
It will be harder to avoid a payment penalty if you report via claims. 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. Make sure you select Performance Year 2023. (Note: As of Jan. 23, CMS hadn't yet added Performance Year 2023 to this tool. It said that the 2023 quality measures would be available on its website in "early 2023.")
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 have the option of using more than one collection type for quality measures. You can, for example, report two measures via claims and four different measures via the IRIS Registry.
Using different collection types to report the same measure. 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 QCDR measures. The QCDR measures can only be reported via the IRIS Registry.
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 2025.
Facility-based scoring isn’t an option for most ophthalmologists. Facility-based scoring will be available to you only 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, 2021, and Sept. 30, 2022.
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 15. (If you started, but didn’t complete, the integration process last year, June 15 is also the deadline for notifying Verana Health 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, 2024.
- Press the “Submit” button to send data to CMS by Jan. 31, 2024.
If you want to manually report MIPS via the IRIS Registry:
- Sign up for manual reporting by Oct. 31. (If you sign up for integrated IRIS Registry–EHR reporting of quality measures, you do not have to sign up separately for manual reporting.)
- Read the step-by-step instructions on how to enter data. Finish manually entering MIPS data by Jan. 31, 2024.
- E-sign a data release consent form by Jan. 31, 2024.
- Press the “Submit” button to send data to CMS by Jan. 31, 2024.
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