This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page.
CMS gives the quality performance category a default weight of 45%, which means that it contributes up to 45 points to your 2019 MIPS final score (0-100 points). The performance period for quality is the full calendar year.
Select One (or More) Ways to Report
For the quality performance category, what reporting mechanisms—or collection types, as CMS is now calling them—can you choose from? This will depend, in part, on whether you have an electronic health record (EHR) system. They include:
And—new this year—CMS has increased your flexibility for using more than one collection type.
Reporting via IRIS Registry–EHR integration. If you integrate your EHR system with the IRIS Registry, an automated process can extract data from your EHRs for up to 42 measures (see Table 7). You would report on both Medicare and non-Medicare patients.
Automated reporting. After the performance year is over, the IRIS Registry will report all applicable quality measures for which you have enough data to report.
You may be able to report on up to 28 ophthalmology-specific IRIS Registry measures. As a qualified clinical data registry (QCDR), the IRIS Registry has been able to develop its own quality measures. In Table 7, these measures have an “IRIS” prefix (e.g., IRIS40: Regaining Vision After Cataract Surgery). But keep in mind that only one of these QCDR measures (IRIS2: Glaucoma—IOP Reduction) currently has a benchmark. Furthermore, you can only report a measure via IRIS Registry–EHR integrated reporting if the IRIS Registry is able to extract the relevant data elements from your EHR system—so the quality measures that are available to you may depend on which EHR system you are using.
Report Manually via the IRIS Registry. If you use the IRIS Registry for manual reporting, you’ll have 57 quality measures to choose from (see Table 8). You would report on both Medicare and non-Medicare patients.
Enjoy access to 28 ophthalmology-specific IRIS Registry measures. The IRIS Registry developed 28 QCDR measures for manual reporting. However, only one of these QCDR measures (IRIS2: Glaucoma—IOP Reduction) currently has a benchmark.
Report via Medicare Part B claims. This involves real-time reporting. Table 9 lists the 16 claims-based measures that are most relevant to ophthalmology. You only report on Medicare Part B patients.
Expanded access to claims-based reporting for small practices, but no longer an option for large practices. In 2019, clinicians in large practices can no longer report quality measures via Medicare Part B claims. However, clinicians in small practices can continue to do so and—new this year—can do so when reporting as a group, not just when reporting as individuals. (See Small or Large Practice? to learn how CMS makes its practice-size determination.)
Other reporting options. If you miss the deadlines for reporting via the IRIS Registry, you may still be able to report electronically via the CMS QPP portal.
Also, some EHR vendors will report quality measures on your behalf. However, you won’t have access to the ophthalmology-specific QCDR quality measures that the IRIS Registry has developed, and your EHR vendor may charge fees for MIPS reporting.
Consider reporting as a group. 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 will 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 –7 % payment adjustment in 2021.
Facility-based scoring available for certain clinicians. Facility-based scoring will only be available to you 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 will be based on claims submitted between Oct. 1, 2017, and Sept. 30, 2018. CMS will only assign you the facility’s quality score if it is higher than your individual quality score. This is unlikely to be an option for many ophthalmologists.
New—Increased Flexibility for Using More Than One Collection Type
What happens if you use more than one collection type? Suppose, for example, you report six measures by Medicare Part B claims and you also report the same six measures manually via the IRIS Registry.
If you did that during the 2018 performance year, CMS would 1) assess your score for the six claims-based submissions, 2) assess your score for the six IRIS Registry–based submissions, and 3) assign you the highest of those two scores (i.e., your score would either be based on the six measures reported by claims or the six measures reported via the IRIS Registry portal).
During the 2019 performance year, however, CMS will make that comparison for individual measures—so your final quality score could, for example, be based on five measures that were reported via the IRIS Registry and one measure reported via claims.
The ACR Measure
It is very unlikely that the All-Cause Hospital Readmission (ACR) measure applies to you. You would need to have a high volume of unplanned readmissions to a hospital within 30 days of an initial discharge. This measure only applies to large groups (16 or more eligible clinicians) that meet the case minimum requirement of 200 cases. Practices don’t need to report this measure; they will be evaluated based on Medicare administrative claims data.)
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