The QPP Quest
Volume 2 Ed. 5 | May 23, 2019
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Hot Off the Press!
The Medicare Promoting Interoperability Program Hardship Exception Application for Eligible Hospitals and Critical Access Hospitals Is Now Available!

The Centers for Medicare & Medicaid Services (CMS) require that all eligible hospitals and critical access hospitals (CAHs) use 2015 Edition-certified electronic health record technology (CEHRT) to meet the Promoting Interoperability program requirements. CMS mandates downward payment adjustments be applied to eligible hospitals and CAHs that are not meaningful users of CEHRT.

Hardship Exception Application Details
  • The deadline for eligible hospitals to submit an application is July 1, 2019.
  • The deadline for CAHs to submit an application is November 30, 2019.

For More Information
Visit the CMS Scoring, Payment Adjustment, and Hardship Information webpage for more information. Visit the CMS Promoting Interoperability webpage for more information.
Quality Payment Program (QPP)
Frequently Asked Question of the Month
Question: What is the difference between the opt-in policy and voluntarily reporting?
 
Answer: The opt-in policy is new for 2019 and allows an eligible clinician (EC) type who meets at least one (1) of the three (3) low-volume thresholds (LVT) to submit data to CMS and possibly earn a positive payment adjustment. It is important to note, if an EC chooses to opt-in, that choice will be irrevocable during the remainder of the performance year and if the EC fails to submit data to CMS or earn the minimum number of required points to remain neutral, the EC will receive a negative payment adjustment. If an EC does not meet any of the three LVT criteria, but would still like to submit, the EC can voluntarily submit data. Should an EC decide to voluntarily report data to CMS, the data will be scored by CMS, but the EC would not be eligible to receive a positive or negative payment adjustment.
Upcoming Learning Forum Friday Events
June 14, 2019
 1 p.m. ET
MIPS Scoreboard Check
Learning objectives:
  • Determine current MIPS performance for all categories.
  • Recognize how to use MIPS data to date to strategize third quarter performance boost.
  • Discuss and compare reporting requirements from 2018 to 2019.
July 12, 2019
 1 p.m. ET
Third Base: QPP Lessons from the Field
Learning objectives:
  • Apply strategies to avoid a negative payment adjustment.
  • Identify common challenges to MIPS reporting.
Did You Miss the May 10 Learning Forum Friday Webinar?
 
Download the webinar recording for Let's Talk QPP: Promoting Interoperability . The presentation slides are also located at https://www.hsag.com/lff .

Do not forget to register for upcoming webinars and browse past webinars.  
Upcoming Webinars for Small Practices
How to Succeed in the Promoting Interoperability Category for Solo and Small Group Practices
Centers for Medicare & Medicaid Services (CMS) Updates
MIPS 2018 Data Submission Period Has Closed; Preliminary Performance Feedback Data for MIPS Now Available
The data submission period for the 2018 Merit-based Incentive Payment System (MIPS) closed on April 2, 2019. The Centers for Medicare & Medicaid Services (CMS) is currently in the process of reviewing all the data submitted.

If you submitted data through the QPP website , you are now able to review your preliminary performance feedback data. However, please keep in mind, this is not your final score or feedback. 
 
Your final score and feedback will be available in July 2019 through the QPP Program website . You will be able to access preliminary and final feedback with the same HCQIS* Access Roles and Profile (HARP) credentials that allowed you to submit and view your data during the submission period. Don’t have a HARP account? Start the process now! Refer to QPP Access User Guide and this video for step-by-step instructions.

*HCQIS = Health Care Quality Information System
Image Source: CMS. Preliminary 2018 Performance Feedback. Accessed on April 9, 2019. Available at www.qpp.cms.gov .
Webinar on MIPS Improvement Activities in 2019
Did You Register for the CMS Web Interface or CAHPS ® for MIPS Survey Yet?

Groups and virtual groups must register by July 1, 2019 at 5:00 p.m. ET , to use the CMS Web Interface and/or administer the Consumer Assessment of Healthcare Providers and Systems® (CAHPS®) for MIPS Survey for 2019.
QPP Look-Up Tool for APM Entities

CMS has added secure access to the Quality Payment Program Eligibility & Reporting page for the following Alternative Payment Models (APMs): Shared Savings Program, Next Generation Accountable Care Organization, and Comprehensive Primary Care Plus.
The new capabilities allow APM entities to download a list of their clinicians. 

For More Information
June Health Observances
Men's Health Month

Here are the Merit-based Incentive Payment System (MIPS) measures associated with this month's men's health observance:
  • Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy — Quality ID: 462
  • Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate cancer Patients — Quality ID: 102
  • Prostate Cancer: Combination Andrgen Deprivation Therapy for High-Risk or Very High-Risk Prostate Cancer — Quality ID: 104
  • Radical Prostatectomy Pathology Reporting – Quality ID: 250
Alzheimer's Disease & Brain Awareness Month

Visit the Alheimer's Association website to join their "Go Purple" campaign at http://www.alz.org/abam/overview.asp.
  • Dementia: Associated Behavioral and Psychiatric Symptoms Screening and Management – Quality ID: 283
  • Dementia: Cognitive Assessment – Quality ID: 281
  • Dementia: Education and Support of Caregivers for Patients with Dementia – Quality ID: 288
  • Dementia: Functional Status Assessment – Quality ID: 282
  • Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia – Quality ID: 286
Cataract Awareness Month

Here are the MIPS measures associated with this month's cataract awareness observance:
  • Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) – Quality ID: 388
  • Cataract Surgery: Difference Between Planned and Final Refraction – Quality ID: 389
  • Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery – Quality ID: 191
  • Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures – Quality ID: 192
  • Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery – Quality ID: 303
  • Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery – Quality ID: 304
News and Networking
Volunteer as a QPP Clinician Champion!
CMS is in search of candidates to voluntarily participate as Quality Payment Program Clinician Champions. CMS is hoping to identify potential candidates. Check out the Fact Sheet and Nomination Form . Interested candidates must return an application by May 31, 2019 to the address provided in the Nomination Form, and CMS will notify those selected later this summer.
CMS Call for Quality Measures

CMS reminds you to submit Quality measures for consideration for future years of the MIPS by June 3, 2019.

The MIPS Annual Call for Quality measures process allows clinicians, professional associations, and medical societies that represent eligible clinicians, researchers, consumer groups, and others to identify and submit measure recommendations in the following domains:
  • Patient safety
  • Person- and caregiver-centered experience and outcomes
  • Communication and care coordination
  • Effective clinical care
  • Community/population health
  • Efficiency and cost reduction

If you are interested in proposing new Quality Measures for MIPS, you can do so through the Office of the National Coordinator Project Tracking System ( ONC-JIRA ) system. Visit the pre-rule-making website on CMS.gov to learn more about JIRA and how to submit measures for consideration.
CMS Call for Promoting Interoperability (PI) Measures and Improvement Activities (IA)
CMS reminds you to submit PI measures and IA for consideration for future years of the MIPS.

How to Submit Measures and Activities
If you are interested in proposing new measures and activities for MIPS, review the Call for Measures and Activities Overview fact sheet (Zip) and fill out and submit the following forms during the specified submission periods:
  • IA Performance Category (submission period ends July 1, 2019 for 2021 activities)
  • PI Performance Category (submission period ends July 1, 2019 for 2021 measures)

For More Information
Download the Call for Measures and Activities materials (Zip) on the QPP Resources Library. A webinar recording on the MIPS Annual Call for Quality, PI measures, and IA, and is also available on the QPP Webinar Library.
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Subscribe to HSAG's QPP Quest Digest
Invite your practice staff, practices you refer patients to, and other colleagues to subscribe to HSAG’s QPP Quest Digest!   Stay informed of all monthly QPP updates, deadlines, no-cost webinars and best practices by subscribing  here .
CMS QPP Listserv
Don't forget to sign up on the  CMS.gov 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.
Health Services Advisory Group
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-D.1-05172019-01