MIPS FOR 2018: WHAT WE KNOW SO FAR!
MEETING THE REQUIREMENTS BY REPORTING QUALITY MEASURES
For 2018, CMS requires you to accumulate at least 15 points in MIPS (or else you will be penalized in 2020), and one way to do this is to concentrate on the Quality Measures. This may be a relatively easy area for you to focus on. Many physicians are already familiar with the Quality Measures from CMS’s PQRS program; no EHR is required, and you may already be doing some of the activities in your day-to-day practice.
REMINDER: IF YOU JUST WANT TO USE THE MIPS QUALITY MEASURES TO AVOID THE 2020 PENALTY:
Before you learn how to access and submit 2018 Quality Measures, please read the following if all you want to do is avoid the 2020 penalty. After you’ve read it, follow the directions farther down in this memo, on how to access and submit the 2018 Quality Measures. In future communications we will discuss MIPS bonuses and how to work toward them.
TO AVOID THE 2020 PENALTY, YOU MUST REPORT AT LEAST SIX (6) QUALITY MEASURES. (Note: Some measures are “Process” measures, some are “Outcome measures.” Of the six measures that you choose, one must be an “Outcome” measure. If there’s no outcome measure that applies to your specialty, you can submit a “High priority” measure instead.)
Small practices (1-15 clinicians): For EACH Quality Measure, you must report that measure for at least one visit (one point in time) during the performance period. Also, for EACH Quality Measure, you must report that measure on at least one patient. This patient must be in the category that CMS has defined for that particular measure; for the Breast Cancer Screening measure (for example), the patient must be in the “Women aged 51 to 74” category. (CMS sometimes uses technical terms for patients who are in the defined categories for particular measures. You may see the term “qualifying patients” – or even the term “denominator-eligible patients.”)
Summing up for small practices: For each measure, you must report the measure at least once – and on at least one patient who qualifies for that measure.
Larger practices (>15 clinicians): For EACH quality measure, you must report that measure on at least 60 percent of the patients who qualify for that measure. Also: For EACH quality measure, you must report that measure for the full calendar year. A note about that “full calendar year” requirement: In 2017, CMS stated that full-year reporting was going to be required in 2018. However, CMS did not post the specific information that physicians would have needed to meet the full-year requirement in a timely manner. So, it is not clear that these physicians would have been able to comply. At present, the AMA and other physician organizations are lobbying to have the reporting period reduced from “the full calendar year” to “any 90-day period during 2018.” We will keep you apprised of developments as they occur.
Summing up for larger practices: For each measure, you must report on at least 60 percent of your patients who qualify for that measure. And until further notice, our information is that you must report throughout the calendar year.
To review whether it is more expedient to report as an Individual versus a Group, information is available at https://qpp.cms.gov/mips/individual-or-group-participation.
Zeroing in on the Quality Measures
For now, let’s assume that you plan to report Quality Measures via your Medicare claims, rather than other avenues that might cost you money (such as a registry). CMS has a list of Quality Measures you can choose from, including measures that can be reported right on your claims. That’s important; not all measures can be reported on claims.
We’ll tell you how to find this list of Quality Measures and what you should do then. We’ll use the “Breast Cancer Screening” measure as an example, and we’ll ask you to follow two detailed Notes at the end of this memo. You may want to print those Notes out, to look at as you go along.
And please note this CRUCIAL point: Each Quality Measure has its own unique Quality ID Number (which you must jot down), but you won’t put the Quality ID Number on the claim. Instead, on the claim you’ll use a special reporting code called the Quality-Data Code (QCD). Each Quality Measure has its own unique Quality-Data Code. (Actually, many Quality Measures have more than one code – you’ll find out more about this below.)
Step One: How to locate CMS’s list of Quality Measures: Here, you’ll need to do a bit of technical navigation. See Note 1, “Navigating CMS’s List of Quality Measures,” at the end of this document. Click on the link in that note and follow the directions. Then, once you’ve located the list of Quality Measures, glance over the whole list and choose some measures that are appropriate for your practice, just to begin with (you may change your mind about some of them later). Some of the measures may be specific to your specialty. Others may be more general but may still be part of your day-to-day practice routine.
Step Two: How to locate the Quality-Data Code: For any Quality Measure, you’ll need to find the Quality-Data Code to put on the claim. See Note 2, “Finding the Quality-Data Code for a Quality Measure,” at the end of this document, and follow the directions carefully. You’ll be able to dig out the Quality-Data Code, but the process is a bit complicated and you need to know exactly how to proceed.
Step Three: How to put the Quality-Data code on the claim: On paper claims: You put the Quality-Data Code(s) in the Procedures field (24D), just below the line where you've entered the Procedure Code. (Note: Don’t forget the Charges field (24F). You'll need to put $0.01 in that field.) Electronic claims: You will need to work with your vendor to be able to put the Quality-Data Code(s) on the claim.
Step Four: How to submit the claim: When must we submit the claim? The Quality Measures must be reported for dates of service in 2018, but the “window” for submitting the claim with dates of service in 2018 will be open until March 31, 2019. Can we resubmit a claim just to add or correct a Quality-Data Code? Unfortunately, no.
Notes 1 and 2 –
You may find it helpful to print out these notes, to refer to as you navigate the websites –
Note 1: NAVIGATING CMS’S LISTS OF QUALITY MEASURES
First, click on https://qpp.cms.gov. Click on “Explore Measures,” at left. This brings you to the Explore Measures page.
Scroll down to “2018 Quality Measures.” Keep scrolling a bit more, to just under “Search.” You’ll see three boxes: Measure Type, Specialty Measure Set and Submission Method.
In Submission Method, look at the dropdown menu and click on Claims. (Be sure to click on “claims” – you need to limit your options because you want to report right on your claims, and only certain measures are reportable via claims.)
In Specialty Measure Set, look at the dropdown menu and click on your specialty. Then, scroll down a bit. If you have clicked on Obstetrics/Gynecology you will see 13 measures, each with a short description. The number of measures varies with the specialty. If you click on Internal Medicine, for example, you’ll see 20 measures.
Suppose you are interested in the first measure in the Obstetrics/Gynecology list, titled “Breast Cancer Screening.” Now, do the following! This is important: At bottom left, click on “View Details” and scroll down a tiny bit more. On the lower left you’ll see a column titled “Measure Numbers.” At the bottom of this column you’ll see “Quality ID: 112.” That is the Quality ID Number. For the Breast Cancer Screening measure, it’s 112.
You should make a note of that Quality ID Number if you think you might like to report on this Quality Measure. After you have noted the Quality ID Number, click “Hide details” and this information will no longer be shown.
Also, notice that the word “Process” appears just under the measure title (“Breast Cancer Screening”). As we’ve said: If you are choosing six measures, one of your measures has to be an “Outcome” measure rather than a “Process” measure. Would you like to see a list of “Outcome” measures? Scroll back up to the Measure Type panel and click “Outcome” - and, under Specialty Measure Set, click on All. You’ll see a list of Outcome Measures. They may be general, but some of them may be appropriate for your practice even if they are not within your specific specialty.
If there’s no outcome measure that applies to your practice, you can submit a “High priority” measure instead. Looking through the entire list of the measures for your specialty, you may see several “High Priority Measures.”
Once you’ve chosen a measure, you need to find the Quality-Data Code for that measure, to put on your claim. See Note 2, below.
Note 2: FINDING THE QUALITY-DATA CODE FOR A QUALITY MEASURE
Starting out: Glance over the Resource Library list
Click on: https://qpp.cms.gov/docs/QPP_quality_measure_specifications.zip. This takes you to a page titled Quality Payment Program Resource Library.
Look down the page. You’ll see “Find 2018 resources by provider type or topic.” Click on that.
Now you are at a page titled “2018 Resources.” It contains a General Information section, followed by a MIPS section.
Look down at the MIPS section. You’ll see a subsection titled Quality, which offers you choices. You can choose Claims Registry Measures 001-050, or - and so on! (Note: You’ll see the word “registry” here, but don’t worry about it.)
Suppose you are interested in the “Breast Cancer Screening” measure. Its Quality ID number is 112, so we choose Claims Registry Measures 101-150 (since 112 is within that range of numbers). We click on it. We arrive at the “License” page. Scroll down and click “Accept.”
Choosing the correct Measure Specifications document (a PDF)
At the bottom left corner of your screen, a rectangle will appear titled 2018-Claims-Regist….z… Click on the rectangle. You’ll see a panel that shows Claims-Registry-Measures-101-150. Click on that.
You’ll see a long list of PDFs. (These are the actual Measure Specifications documents.) They are titled “2018_Measure_102_Registry.pdf,” “2018_Measure_104_Registry.pdf,” and so on.
We want Quality ID Number 112, so we look for 2018_Measure_112_Claims.pdf. You will see two versions for Quality ID Number 112 - one that says "Claims" and one that says "Registry." Be sure to click on the “Claims” version, not the “Registry” version.
You will now see the actual Measure Specifications document. It’s a PDF, numbered “Quality ID #112” and titled “Breast Cancer Screening.” You’ll see a lot of detail, but you should just concentrate on two questions: (1) What Quality-Data Code do I put on the claim? And (2) Which of my patients are going to be suitable for this particular measure – in other words, which ICD-10 diagnosis codes will be appropriate?
What Quality-Data Code do I put on the claim?
Scroll down until you see NUMERATOR, and glance through the NUMERATOR section until you come to "Numerator Quality-Data Coding Options.” Just below "Numerator Quality-Data Coding Options” you'll see five alternative scenarios, each with its own unique code or codes in bold type.
Of those five scenarios, which one best describes what happened in today’s encounter, with this patient? If you actually performed the mammogram you will want to focus on the fourth scenario, titled “Mammogram Performed.” Under that title you will see “Performance Met,” followed by: G9899. That is the Quality-Data Code that you should use if you actually performed the mammogram.
In the other four scenarios, the mammogram was not performed - for various reasons, which you’ll see described. Each scenario has its own specific Quality-Data Code. (Note: You get “MIPS credit” even if you didn’t perform the mammogram – as long as your reason for not performing it fits in with one of these scenarios, and you report using the appropriate Quality-Data Code.)
Which of my patients and encounters will be suitable for this Quality Measure?
Scroll up till you see DENOMINATOR. You’ll see “Women 51 – 74 years of age with a visit during the measurement period,” followed by an explanation (“Denominator Note”). Two paragraphs below, there’s a list of actual CPT and HCPCS codes. If none of those codes applies to this patient encounter, you should not use this measure for this encounter.