This content is excerpted from “MIPS 2023, Part 1” (EyeNet, January 2023). EyeNet’s MIPS content, including its MIPS 2023 supplement, is being published online ahead of print as it becomes available.
Removal of 3-point floor for large practices. For the 2022 performance year, if your reporting for a quality measure included at least 70% of denominator-eligible patients, you could score at least 3 achievement points for it even if you didn’t meet the measure’s 20-patient case minimum and even if the measure didn’t have a benchmark.
For the 2023 performance year, this 3-point floor still applies to small practices but not to large practices. (CMS defines practices as large if they have 16 or more eligible clinicians.)
Reporting Electronic CQMs? If you are reporting electronic clinical quality measures (eCQMs), your EHR system must have 2015-edition Cures Update certification before you generate the data that you will report to CMS.
Clarifying the lifecycle of topped out measures. CMS can designate that a measure is “topped out” for a given collection type. This means that the vast majority of clinicians who report the measure via that collection type have a performance rate so good that there is little room for improvement. If that’s the case for two consecutive years, the measure becomes subject to a 7-point cap. For future performance years, this cap remains in place until either the measure stops being topped out or is eliminated from the MIPS program.
However, if a measure benchmark is topped out one year and CMS isn’t able to create a benchmark for it the following year—because, for example, the measure is suppressed—CMS won’t apply the 7-point cap that second year.
Prioritizing health equity measures. For the quality performance category, you must report at least one outcome measure or—in the unlikely event that no outcome measure is available to you—another type of high priority measure. In 2023, CMS is expanding the definition of high priority measure to include measures pertaining to health equity, which it defines as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identify, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.”
Change in benchmark assignment for administrative claims measures. For a handful of MIPS quality measures, CMS calculates performance rates based on Medicare administrative claims data. Previously, CMS had calculated benchmarks for these measures based on historical data. Starting in 2023, the agency will calculate these benchmarks based on performance year data, which means that the benchmarks won’t be known until the performance year is over. It is very unlikely that any of these administrative claims measures will apply to an ophthalmology practice.
Reporting Manually Via the IRIS Registry?
2023 is the last year for reporting quality measures manually via the IRIS Registry. For MIPS performance year 2023, the Academy and its IRIS Registry partner, Verana Health, are again providing Academy members with the option to report quality measures manually via the IRIS Registry. However, you won’t be able to do so for 2024. Why the change? Although the IRIS Registry was widely used to manually report quality measures for PQRS and for the initial years of MIPS, its use for non-EHR reporting has now dwindled. Furthermore, CMS has said that it will—sooner or later—make electronic reporting the only option for MIPS.
Consider transitioning to EHR ahead of 2024. Before you get started, check which EHR systems can be integrated with the IRIS Registry, and also check EHR resources offered by the AAOE.
Other options. It is expected that you will still be able to report quality measures via claims in 2024. Or you can select another registry to submit quality measures manually.
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