How to Report for MIPS with the IRIS® Registry

Medicare has consolidated the Physician Quality Reporting System and other existing quality-improvement programs into the Quality Payment Program. Most ophthalmologists will likely use the program’s new fee-for-service option – the Merit-Based Incentive Payment System. The Academy’s IRIS Registry can help you meet MIPS reporting requirements and avoid penalties.

How MIPS Works

Physicians have three options for MIPS: 1) Earn a bonus for high performance; 2) Avoid a penalty for successful performance; 3) Earn a future penalty for unsuccessful performance or not reporting at all.

• With the IRIS Registry, you can work toward both a bonus or penalty avoidance.
• Under MIPS, the Centers for Medicare and Medicaid Services evaluates physician performance in four weighted categories.

CMS began counting performance on the cost category.

Using the IRIS Registry to Report MIPS

The IRIS Registry supports reporting for each of the three weighted categories. If your practice reports at the group level for one category, it must do so for all MIPS categories.

Quality

Use the IRIS Registry to meet the reporting requirements for the quality category using the EHR-integration option OR the IRIS Registry web portal (cannot combine both for quality).

• CMS offers bonus points for 1) reporting on more than one outcomes or high priority measures and 2) for electronically submitting quality measures.
• With an EHR system: The IRIS Registry will submit the measures on which you would earn the highest points, automatically maximizing your score.
• Benchmarking: All EHR-integrated IRIS Registry participants that report the electronic clinical quality measures will be compared to the CMS published EHR benchmarks for MIPS scoring purposes. CMS will know to use the EHR-benchmarks because IRIS Registry will submit the CQM performance data for those practices using a file for electronic clinical quality measures, as CMS determines the appropriate benchmark to use based on the submission file type. This is different than measures reported using the IRIS Registry web portal. Practices manually entering quality measure data using the IRIS Registry web portal will be compared to the registry benchmarks.
• ACOs: Practices part of an ACO can report quality separately from the ACO to be considered if for any reason the ACO fails. Providers joining ACO-participating practices after Aug. 31 should also report quality measures separately.

Promoting Interoperability

CMS does not require EHR use for MIPS participation, but you must use an EHR system to meet the reporting criteria for the promoting interoperability category.

• You don’t need to separately attest with CMS; you can submit promoting interoperability directly through the IRIS Registry web portal.
• Participation in the IRIS Registry is not sufficient to meet the criteria for this category; providers must use their certified EHR system to meet the required measures for that category.
• The Iris Registry is a clinical data registry that can count towards 2020 promoting interoperability.

Improvement Activities:

CMS offers a number of activities that may apply to ophthalmologists. Points for activities vary based on practice size. All physicians must complete at least one activity for this category to avoid a penalty.

• The IRIS Registry supports reporting for over 60 activities.
• With an EHR system: Participation in the IRIS Registry qualifies you for four of these 33 activities. You can report for additional activities if desired.
• Without an EHR system: Attest to some of these activities through the IRIS Registry web portal.

In addition to attesting, all practices should maintain documentation supporting completion of each activity, in the event of a future audit.

Qualified Clinical Data Registry

CMS approved the IRIS Registry in 2020 as a Qualified Clinical Data Registry.