• MIPS Manual 2017—Know the Basics: Next Steps

    Written By: Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Molly Peltzman, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content was excerpted from EyeNet’s MIPS Manual 2017.

    Decide how you will report. You don’t have to use the same reporting mechanism across all performance categories. For instance, you can report quality and improvement activities using the IRIS Registry and report ACI using your EHR vendor. However, within each performance category, you typically must use just 1 reporting mechanism—the exception is the Consumer Assessment of Health Providers and Systems (CAHPS) for MIPS survey, which can be used as a second data submission mechanism for quality—but this won’t be applicable for most ophthalmologists.

    Consider group reporting. Your practice can report as a group if it includes at least 2 MIPS participants. For the pros and cons of reporting as part of a group, see “The Pros and Cons of Group Reporting.”

    Make the most of Academy and AAOE resources. See “MIPS Resources.”

    Physician leadership will be critical. Although CMS has made it easy to avoid the payment penalty during MIPS’ first year, the reporting requirements—and the payment penalties—are expected to ramp up rapidly over the next 2 years. Because so much money will ultimately be at stake, a physician ought to oversee your practice’s MIPS planning and processes, which should be implemented by experienced staff who are knowledgeable about MIPS’ precursors (the PQRS, EHR meaningful use, and value-based modifier programs).

    Table 2: Selecting Your Reporting Mechanism(s)

    Reporting Mechanism Can Be Used to Report: Need EHR? Used By: It Involves:
    Medicare Claims Quality No Individuals Real-time reporting
    Attest Via CMS Web Portal Improvement activities, ACI No Individuals or groups Manual data entry
    IRIS Registry Web Portal Improvement activities, ACI,† quality No Individuals or groups Manual data entry
    IRIS Registry/EHR Integration Quality Yes Individuals or groups Automated data extraction
    EHR Vendor Improvement activities,* ACI,* quality* Yes Individuals or groups A possible fee

    * Contact your EHR vendor to confirm which performance categories you can report through them; also ask the vendor for its reporting deadlines.

    † EHR is not needed to use the portal, but is needed to perform ACI measures.

    Four factors to consider when selecting your reporting mechanism(s):

    • For each performance category, you can only use 1 reporting mechanism.
    • You don’t have to use the same reporting mechanism for all performance categories.
    • For a given performance category (e.g., improvement activities), everybody in the group must use the same reporting mechanism (e.g., the IRIS Registry web portal).
    • The IRIS Registry offers the least burdensome and most ophthalmology-focused reporting options. 

    CMS Web Portal Versus CMS Web Interface

    The MIPS program uses 2 similar terms for 2 very distinct reporting options—the CMS web portal and the CMS Web Interface.

    The CMS web portal can be used to report ACI measures and improvement activities. CMS has said that when this attestation portal goes live, you will find a link for it at https://qpp.cms.gov. The Academy recommends that you use the IRIS Registry web portal, which is geared exclusively toward ophthalmology.

    The CMS Web Interface is used for reporting quality by some large practices that provide primary care services. It is a quality reporting option that has its own reporting requirements, its own set of quality measures (mostly primary care–based), and a 12-month reporting period. It replaces the PQRS program’s GPRO Web Interface and is only available to practices that have at least 25 MIPS eligible clinicians reporting quality data.


    Next: Know the Basics: Improvement Activities Overview

    Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

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