The QPP Quest
Volume 3 Ed. 5 | May 21, 2020
Hot Off the Press!
2020 MIPS Promoting Interoperability (PI) Performance Category Hardship Exception Application Is Available

Certified electronic health record technology (CEHRT) is required for participation in the PI category. Under the Merit-based Incentive Payment System (MIPS), you may qualify for a re-weighting of the PI performance category (to 0%) if you meet certain criteria. The application deadline is December 31, 2020.

MIPS-eligible clinicians, groups, and virtual groups may submit a MIPS Promoting Interoperability Performance Category Hardship Exception application citing one of the following specified reasons:

  • You are a small practice
  • You have decertified electronic health record (EHR) technology
  • You have insufficient Internet connectivity
  • You face extreme and uncontrollable circumstances, such as disaster, practice closure, severe financial distress, or vendor issues
  • You lack control over the availability of CEHRT

2020 Extreme and Uncontrollable Circumstances Exception Application Window Is Now Open!
MIPS-eligible clinicians, groups, and virtual groups may submit an application for re-weighting of any or all MIPS performance categories if they have been affected by extreme and uncontrollable circumstances that impact these categories. The Extreme and Uncontrollable Circumstances Exception application deadline is December 31, 2020.

Extreme and uncontrollable circumstances are defined as rare events entirely outside of your control and the control of the facility in which you practice. These circumstances would:
  • Cause you to be unable to collect information necessary to submit for a MIPS performance category.
  • Cause you to be unable to submit information that would be used to score a MIPS performance category for an extended period of time (e.g., if you were unable to collect data for the Quality performance category for 3 months), and/or;
  • Impact your normal processes, affecting your performance on Cost measures other administrative claims measures.

For the MIPS 2019 performance period, the Centers for Medicare & Medicaid Services (CMS) added flexibilities to allow the healthcare delivery system to focus on the 2019 Novel Coronavirus (COVID-19) response. The automatic Extreme and Uncontrollable Circumstances policy was extended to all MIPS-eligible clinicians. MIPS-eligible clinicians who were not able to submit any 2019 MIPS data by April 30, 2020 will receive a neutral payment adjustment for the 2021 MIPS payment year.

Please Note:
Beginning in January 2020, a Health Care Quality Information Systems ( HCQIS) Access Roles and Profile (HARP) account is required to submit a MIPS PI Hardship Exception Application or an Extreme and Uncontrollable Circumstances Application. Log into the Quality Payment Program (QPP) portal with your credentials, click the ‘Exceptions Application’ on the left-hand navigation, and then select the application to complete and submit. 
For more information on how to obtain a HARP account, refer to the Register for a HARP Account document in the  QPP Access User Guide .
MIPS 2019 Preliminary Performance Feedback Data Now Available
If you submitted data through the QPP , you may now review your 2019 MIPS preliminary performance feedback data. Please keep in mind that this is not your final score or feedback. 

Your final score and feedback will be available in July 2020. Between now and July, your score could change based on the following:
  • All-Cause Readmission Measure for the Quality performance category
  • Claims measures to include the 60-day run-out period
  • CAHPS® for MIPS Survey results
  • Reweighting based on COVID-19 Extreme and Uncontrollable Circumstances Applications (submitted in April)
  • Quality and Cost performance category scores from facility-based measurement
  • Improvement Study participation and results
  • Creation of performance period benchmarks for Quality measures that did not have a historical benchmark 

* CAHPS® = Consumer Assessment of Healthcare Providers and Systems®
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
HSAG Year 4 MIPS Participation Check-In

Each year, Health Services Advisory Group (HSAG) checks in with every eligible clinician and practice to ensure your plans for MIPS reporting are on track. You may receive phone calls, emails, and or fax communication from us throughout the year. Our goal is to ensure you are prepared to submit your best MIPS score, so we appreciate your time speaking with us and look forward to hearing your MIPS reporting plans this year. If your practice knows your MIPS reporting plans for 2020 now, click here to let us know. By submitting your MIPS participation plans online, we will not reach out via phone, and you can contact us when you need us!

HSAG is 1 of 11 organizations awarded by CMS as a QPP Technical Assistance Support Contractor. Since 2017, HSAG has been your trusted resource, available to Medicare providers in Arizona, California, Hawaii, New Mexico, and the U.S. Virgin Islands. Also, in partnership with Alliant Quality, HSAG is Florida’s technical assistance contractor for the QPP. We provide assistance on MIPS and Alternative Payment Models (APMs); two reporting paths under the QPP. Our services are provided at no cost to you.
QPP Frequently Asked Question of the Month
Question: What are MIPS Value Pathways?
Answer: MIPS Value Pathways (MVPs) represent a participation framework that begins with the 2021 Performance Period. T he goal is to move away from siloed activities and measures to an aligned set of measure options relevant to a clinician's scope of practice and meaningful to patient care.

To learn more, please visit the MIPS Value Pathways page of the QPP website. Additionally, QPP will be hosting educational webinars to provide more information about the MVPs. Upcoming public events and recordings will be posted to the QPP Webinar Library .

Question: How will I know if my MIPS Promoting Interoperability Performance Category Hardship Exception or Extreme and Uncontrollable Circumstances Exception Application has been approved?

Answer: You will be notified by email if your request was approved or denied. You will also be able to check the status of your application by signing into QPP. If approved, this will also be added to your eligibility profile in the QPP Participation Status Tool , but may not appear in the lookup tool until the submission window is open in 2021.
New QPP Tools and Resources
Upcoming Webinars for Small Practices
Understanding How to Implement Telehealth Services: Implications for Solo and Small Group Practices
Tuesday, May 26, 2020
 3:30 p.m. 4:30 p.m. ET
Thursday, May 28, 2020
 11:00 a.m. 12:00 p.m. ET
News and Networking
Mental Health Awareness Month  
May is National Mental Health Awareness Month and a great opportunity to raise awareness about mental health conditions and the importance of good mental health for everyone.
Information and materials to share can be found online at:
MIPS Reporting Tips
Below are a few Quality Measures and Improvements Activities that focus on mental health. Use the MIPS Explore Measures and Activities Tool to identify other applicable measures for your patient population.
PCP = primary care physician
MH = mental health
CMS COVID-19 Stakeholder Call Recordings Available  
CMS has been hosting regular calls with a variety of clinicians, hospitals, other facilities, and states in an effort to keep stakeholders updated on their Novel Coronavirus 2019 (COVID-19) efforts. CMS understands that not everyone is available to attend the calls live, and is sharing access to the call recordings along with transcripts on the following link: . CMS will continue to host calls and share information through their list serves and media.

To keep up with the important work of the White House Coronavirus Task Force in response to COVID-19, visit https:/ . For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website .
COVID-19 Resources and Preparedness
In light of the COVID-19 pandemic, HSAG understands the priority to keep your patients and staff safe.

COVID-19 Resources:

CDC = Centers for Disease Control and Prevention 
MIPS Quality Mentions
HSAG Congratulates 2019 Million Hearts ® Hypertension Control Champions 
In honor of Blood Pressure Education Month,  this month is a great time to discuss goal setting to improve blood pressure control in your practice. Under the MIPS Quality performance category, review  Quality ID: #236: Controlling High Blood Pressure  with your practice and contact the HSAG QPP Assistance line to get assistance on launching a quality improvement initiative to improve your patients' blood pressure.
Million Hearts® has recognized 17 solo practitioners, large health systems, community health centers, and specialty groups as 2019 Hypertension Control Champions. In their work, these Champions were able to achieve blood pressure control for at least 80% of their adult patients with hypertension. Together, the 2019 Champions cared for nearly 360,000 adults. HSAG congratulates all practices and would like to personally recognize, Mid-Florida Primary Care. Ravi P Gupta, MD, opened Mid-Florida Primary Care in 2002, a small rural internal medicine practice with two locations and 5 providers in Leesburg, FL. For the past 3 years, Mid-Florida Primary Care has maintained their NCQA and URAC (Utilization Review Accreditation Commission)( PCMH(Patient Centered Medical Home) certification.
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CMS QPP Listserv
Don't forget to sign up on the QPP website . Once you've accessed the QPP page, scroll to  [Subscribe to Updates]  at the bottom of the page and insert your email address before clicking  [Subscribe] . The QPP listserv is a valuable resource to stay informed of webinars and important QPP deadlines.