You can be your practice’s reporting hero for the Merit-Based Incentive Payment System by getting a head start on 2020 reporting. Following the steps in this outline will help you keep a sane and steady pace and avoid undue stress as deadlines draw near.
What your practice should have done by now
- Review the resources on org/medicare, especially the small or large practice roadmaps.
Tip: bookmark these web pages.
- Assemble your practice’s MIPS team. Your team should include:
- a primary MIPS point person (administrator)
- a physician champion
- a cross-trained administrator to provide back up
Tip: Ideally, everyone on your MIPS team should be an Academy or AAOE member so they can access all MIPS and IRIS® Registry related information on the Academy’s website (most of this information requires member login).
Tip: Ensure your MIPS team receives all the information they need to be successful. Ask the Academy members in your practice to share all MIPS- and IRIS Registry-related information with the team. (For example, the MIPS supplement that will arrive with your May issue of EyeNet® Magazine.)
- Determine your plan of action for the year.
- Make sure all of your clinicians understand the impact of their scores on reimbursement.
- Decide whether your clinicians will report as a group or as individuals.
- If reporting at a group level, communicate the chosen measures to all clinicians in your practice.
- Set your practice’s goal.
- Do you want to earn a small incentive, or do you just want to avoid the penalty?
- Determine how you will report quality.
- If you have an electronic health record (EHR) system, are you integrated with the IRIS Registry?
- If you do not have an EHR system, will you report via claims or through the IRIS Registry web portal?
- If you are reporting via claims, you should start as soon as possible to increase your chances of meeting this year’s 70% data completeness threshold.
What your practice should do by March 31 if you are reporting MIPS via the IRIS Registry
- Review the quality measure changes for 2020.
- Many measures now have restricted points. Check the benchmark table in the measure specifications for details.
- Some measures were discontinued.
- Six IRIS Registry QCDR measures were given benchmarks in 2020.
- These measures are IRIS 1, IRIS 2, IRIS 13, IRIS 17, IRIS 23 and IRIS 26.
- If you are reporting manually via the IRIS Registry web portal, select your quality measures.
- Pay close attention to the benchmark tables and the points available for expected performance rates.
- Practices planning to report 70% of their patients manually should pick carefully
- Set up a workflow that allows staff to keep up with the manual entry of the quality data in the IRIS Registry.
- Read EyeNet Magazine’s MIPS 2020 supplement, which is available online and will be included in the May print issue.
- Choose which improvement activities you’ll do in 2020.
- Practices with a special status—such as small practices and rural ones—should perform one high or two medium weighted activities.
- Large practices should perform two high or four medium weighted activities.
New in 2020: If you are reporting as a group, at least 50% of the providers in your practice must complete each activity that you report.
Tip: Include dates in your documentation of improvement activities so you can prove they were performed for at least 90 days. (For documentation suggestions, see the detailed activity listings.)
What your practice should do every quarter (if your EHR system is a 2015-edition CEHRT)
- Review the promoting interoperability measures to make sure the required measures are met.
- For example: How will you make sure at least one patient accesses their health record remotely?
- Run your EHR system’s promoting interoperability reports (if available) to see how you are doing.
- Identify any deficient measures and take action (for example, adjust workflows or contact your vendor for resolution).
- Set reminders on your calendar to review your promoting interoperability performance no less than once per quarter.
- Look over your IRIS Registry dashboard and verify that your practice’s data for quality measures was pulled in correctly.
- Confirm that your quality data is:
- Mapped properly to the IRIS Registry.
- Being recorded properly in your EHR system.
- Submit a help desk ticket as soon as you find a mistake in your data. Don’t wait until the end of the year.
- Give each care provider their IRIS Registry report so they can see their performance across the quality measures.
For practices with an EHR system that is not certified as a 2015-edition CEHRT
- If your EHR system will not be certified before the end of 2020, make a note on your calendar to submit the EHR Hardship application via the CMS website in August, which is when the agency usually starts accepting applications.
- If your EHR system will be certified by the end of 2020, familiarize yourself with the promoting interoperability measures and the reports available in your EHR system.