MIPS: Important Items to Do in October
October 12, 2018
written by Sharon Phelps
Wow, time flies. We’ve reached the last quarter of 2018, and there are some important things to do in the last few months of this year to finish up 2017 Merit-based Incentive Payment System (MIPS) and prepare to report your 2018 performance results.
The MOST IMPORTANT item to do:
Review your 2017 MIPS Performance Report. Sign into the Quality Payment Program (QPP) portal and review your 2017 performance report. If you find errors, you have until MONDAY, OCTOBER 15, 2018, to file a Targeted Review to have the Centers for Medicare & Medicaid Services (CMS) review your 2017 performance report and score.
The link to file a Targeted Review is in a large, blue button at the bottom of the page. You CANNOT file a Targeted Review unless you are signed into the QPP Portal. If you do not have access to sign into the QPP Portal, you can find instructions here.
Other important items to do:
1. Determine whether you can or should file a hardship application for the Promoting Interoperability category. The application period closes December 31, 2018. Reasons for filing a hardship application include:
- MIPS-eligible clinicians in small practices (15 or fewer NPIs billing under a single TIN) – This is a new exception for 2018.
- MIPS-eligible clinicians using decertified electronic health record (EHR) technology
- Insufficient Internet connectivity
- Extreme and uncontrollable circumstances
- Lack of control over the availability of certified EHR (CEHR)
Note: Clinicians with the following Special Statuses will be automatically reweighted and do not need to file a hardship application:
- Hospital-based MIPS-eligible clinicians
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Non-patient facing clinicians
- Ambulatory Surgical Center (ASC)-based MIPS-eligible clinicians
- The application is relatively simple to fill out, and you do not need to access the QPP portal to complete the steps. More information on the hardship application is located here.
2. If you are reporting in the Promoting Interoperability category, make sure you complete your Security Risk Assessment by December 31, 2018. To be HIPAA-compliant, health care providers must conduct a HIPAA security risk analysis (SRA) to determine areas of security vulnerabilities. Once gaps are discovered, remediation plans must be formalized to correct them. Conducting a SRA each year is a required component of the Promoting Interoperability category. But more importantly, a SRA will help protect patient records and allow you to practice medicine without fear of audits and government fines. Not a HIPAA guru? We have resources to help. Contact Susan Clarke, certified health care information security and privacy practitioner at Mountain-Pacific at (307) 248-8179 or at firstname.lastname@example.org.
3. For solo practitioners or small clinics with 10 or fewer, consider whether being part of a Virtual Group would be beneficial for your clinic. You must declare your intent and complete selected steps by December 31, 2018, to be part of a virtual group in 2019. Contact us if you would like further information.
4. Finalize your 2018 MIPS approach:
- Review your quality measure results and determine whether there are areas of opportunity to improve a measure’s score.
- Make sure you have completed your Improvement Activities for a minimum of 90 days (or more if the activity requires it).
- Review your Promoting Interoperability (Advancing Care Information) criteria to determine whether there are areas of opportunity to improve your score.
- Begin compiling documentation for your audit folder.
5. Contact us at email@example.com if you need help or have questions.
Another item that may be of interest: CMS is conducting a field test of 13 new and updated Cost Measures for future use. You can log into the CMS Enterprise Portal to review these reports.
If you are with a specialty practices, you may be interested if you address the following conditions or perform the procedures:
Eleven New Episode-Based Cost Measures Currently under Development:
- Acute Kidney Injury Requiring New Inpatient Dialysis
- Femoral or Inguinal Hernia Repair
- Elective Primary Hip Arthroplasty
- Hemodialysis Access Creation
- Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
- Lower Gastrointestinal Hemorrhage
- Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
- Non-Emergent Coronary Artery Bypass Graft (CABG)
- Psychoses/Related Conditions
- Renal or Ureteral Stone Surgical Treatment
Primary Care providers may wish to review the two cost measures undergoing re-evaluation:
- Total Per Capita Cost (TPCC)
- Medicare Spending Per Beneficiary (MSPB) clinician
Again, if you have any questions, contact us at firstname.lastname@example.org or use the “Leave a Reply” section below, and one of our subject matter experts will get back to you.