Improving Hypertension _ Diabetes Control and Prevention
An e-NEWSLETTER from Quality Insights                                                                                  January 16, 2017

In This Issue
Happy New Year
HappyHappy new year from quality insights

happy new year As you are aware, the Pennsylvania Department of Health (PA DOH) has been awarded a grant from the Centers for Disease Control and Prevention (CDC) to prevent and control diabetes, heart disease, obesity and associated risk factors. Quality Insights  has been awarded the contract under this grant. 

We want to thank you for your commitment to this important work and look forward to our continued collaboration in 2017. Your practice is one of nearly 175 who have committed to this project to date.  Quality Insights is actively recruiting more practices throughout the state to join this initiative, so please let us know if you know of others who might be interested.
Quality Insights has created this distribution group as a means of disseminating current information to your team members. You will be receiving regular updates about the project, as well as any related news announcements, resources and educational opportunities related to this project via these e-bulletins. 
Project Goals & Activities
As a reminder, our goals and activities for this project will be to:
  • Collect monthly data on NQF measure 0018 - Controlling High Blood Pressure
  • Collect monthly data on NQF measure 0059 - Controlling Hemoglobin A1C (HbA1c) levels > 9.0% (poor control) 
  • Focus on undiagnosed hypertension, screening for prediabetes and those at high risk for diabetes
  • Analyze data and workflows and offer recommendations for improvement
  • Create referral processes to Diabetes Self-Management Education (DSME) and Diabetes Prevention Programs (DPP)
  • Encourage use of clinical decision support, evidence-based protocols
  • Increase patient engagement and the use of patient portals for education
  • Create useful tools and resources for your patients and staff
  • Share best practices and lessons learned
CMS QPP News banner
CMSMIPSMany of you will be attesting for the Centers for Medicare & Medicaid Services (CMS) Electronic Health Record (EHR) Incentive programs for 2016 and preparing for changes that are forthcoming with the Merit-based Incentive Payment System (MIPS)/Quality Payment Program. This information will be of value to you and Quality Insights is poised to assist you as you navigate the various programs.

Please find the most recent MIPS/Quality Payment Program announcements from the Centers for Medicare & Medicaid Services (CMS) below.    

money image CMS recently distributed a message about the International Classification of Diseases (ICD)-10-CM (Clinical Modification) and ICD-10-PCS (Procedural Coding System) code updates that went into effect on October 1, 2016.
CMS has examined impact to quality measures and has determined that the ICD-10 code updates will impact CMS's ability to process data reported on certain quality measures for the 4th quarter of calendar year (CY) 2016. Therefore, CMS will not apply the 2017 or 2018 PQRS downward payment adjustments, as applicable, to any individual eligible professional (EP) or group practice that fails to satisfactorily report for CY 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the 4th quarter of CY 2016.
Please refer to the "ICD-10 Code Updates (12-15-2016)" message on the PQRS Spotlight webpage for full information, or view the PQRS ICD-10 Section webpage for frequently asked questions (FAQs) related to these code updates.
For additional assistance, contact the QualityNet Help Desk at 1.866.288.8912 (TTY 1.877.715.6222) from 7:00 a.m. to 7:00 p.m. CT, Monday through Friday, or via email.

Learn more about the official MIPS Improvement Activities (IA), as well as the Advancing Care Information (ACI) category by watching recording of the CMS presentation, held on December 13, 2016. 

The presentation provides details on how you can earn full credit for the IA category of MIPS, which accounts for 15% of your total MIPS score. The Advancing Care Information category, which accounts for 25% of the total MIPS score, is also reviewed. In addition, the presentation explains how to earn bonus points towards your ACI score by selecting specific Improvement Activities.

A list of all the 92 MIPS improvement activities can be downloaded from the Quality Payment Program website.

January 31 icon Clinicians and groups who are eligible for the MIPS program that participate successfully in the Clinical Practice Improvement Activities and Measurement Study will receive full credit for the Improvement Activities category.
CMS is leading this study to examine clinical workflows and data collection methods using different submission systems; understand the challenges clinicians face when collecting and reporting quality data; and make future recommendations for changes that will attempt to eliminate clinician burden, improve quality data collection and reporting, and enhance clinical care.
Study participants will have to meet the following requirements between January and December 2017:
  • Complete at least three survey questionnaires throughout the course of the study.
  • Participate in at least three focus groups.
  • Submit at least three clinician quality performance measures to CMS.
For more information and to apply to participate in the study, please visit the  CMS website.
Completed applications should be submitted to by January 31, 2017.  
CMSWebsiteVisit the CMS Website for New Attestation Resources

The EHR Incentive Programs attestation system will be open from January 3 - February 28, 2017. Providers must attest by the attestation deadline to avoid a 2018 payment adjustment.

To help providers prepare for the 2016 EHR Incentive Programs attestation period, the Centers for Medicare & Medicaid Services (CMS) has released two attestation worksheets for eligible professionals and eligible hospitals and critical access hospitals.

Providers can log their meaningful use measures for each objective in the worksheet and use it as a reference when attesting for the 2016 Medicare EHR Incentive Program in CMS' Registration and Attestation System.
TransMIPSLearn More about the Transition to MIPS

webinar Tuesday, January 24, 2017
2:00 p.m. to 3:30 p.m.  
Join the Centers for Medicare & Medicaid Services (CMS) on January 24 for the National Provider Call, Transitioning from Quality Programs to MIPS.
During this webinar, CMS will provide an overview on the transition to the Quality Payment Program, how current programs will be streamlined into the Merit-based Incentive Payment System, and key milestones for PQRS, EHR, VM, and MIPS programs. A question and answer portion will be held at the end of the webinar. 
Register Now
Space for these webinars is limited. Register now to secure your spot.

Have a specific question about the Quality Payment Program? Please e-mail
For More Information
To learn more about the Quality Payment Program, visit the Quality Payment Program website. To review presentations from previous webinars, visit the Quality Payment Program Events page.

FAQFind Out More about Calculations for Objectives and Measures Requiring Patient Action in the EHR Incentive Programs

FAQ CMS recently updated an FAQ to provide information about calculations for EHR Incentive Programs objectives and measures requiring patient action. We encourage you to stay informed by taking a few minutes to review the updated information below.

Question: In calculating the meaningful use objectives requiring patient action, if a patient sends a message or accesses his/her health information made available by their eligible professional (EP), can the other EPs in the practice get credit for the patient's action in meeting the objectives?

Answer: If attribution of the message is impossible (it absolutely cannot be determined who from the group practice sent it), it may be counted in the numerator for any provider within the group sharing the CEHRT who has contributed information to the patient's record, if that provider also has the patient in their denominator for the EHR reporting period. However, if the message is attributed to a specific provider, then it cannot count. The transitive effect applies to the Secure Electronic Messaging objective, the second measure of the Patient Electronic Access (View, Download and Transmit) objective, and the Patient Specific Education objective. (FAQ12825)

For More Information
For more information about the EHR Incentive Programs, visit the EHR Incentive Programs page on the CMS website
contact information

For more details about the Improving Hypertension and Diabetes Care & Prevention project, please email Rhonda Dodson or call 1.800.642.8686, Ext. 7711.
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