MIPS Reporting: Submitting Data through QPP.CMS.GOV

Sam Ross, QPP Advisor/Manager

January 31, 2018

Visit our website at http://qpp-il.org! We will help you navigate the complexities of the new CMS payment models so you can focus on what you do best – taking extraordinary care of your patients.

When you sign up for the QPP Resource Center, you get access to resources that help you establish your baseline, identify goals, learn about requirements, and monitor progress. Plus, QPP Advisors are available to answer questions as they come up. All assistance is offered free-of-charge thanks to a grant from CMS.

Agenda

• Brief MACRA/QPP Overview

• QPP.CMS.GOV Sign In and Navigation

• Entering Data for MIPS Categories• Quality• Advancing Care Information• Improvement Activities

• Additional Considerations and References

Brief MACRA/QPP Overview

MACRA (2015)

• Repeals “Sustainable Growth Rate”

• Streamlines multiple quality programs

• Expands pathways for level of risk and reward

• Supports multi-payer initiatives

2017 QPP Eligibility

1) Billing > $30,000 and treating 100+ Medicare patients per year (MIPS)

or

2) Treating 20% patients/receiving 25% of Medicare payments through an Advanced Alternative Payment Model (AAPM)

Merit-based Incentive Payment

System (MIPS)

Advanced Alternative

Payment Models (AAPM)

2017 QPP Timeline

Sign In and Navigation

QPP Home Page

• Visit https://qpp.cms.gov• Click “Sign In” at top right

QPP Sign In Page

• Enter EIDM User ID and Password

• Click the box for “Yes, I agree.” to the statement of truth

• Click the Sign In button

Verify One-Time Code

• A code will be sent to the Multi-Factor Authentication (MFA) device registered with EIDM account (phone, email, voice)

• Retrieve the code, enter into the text box, and click “Submit Code” button

Account Dashboard

• Practices for which your EIDM account can submit are displayed• Special status (small practice, non-patient facing, HPSA, rural, hospital-

based, ASC) identified for each practice

Manage User Access Page

• Click “Manage User Access”• Connected practices and permissions display with link to CMS Portal to

add/update/remove user access to TINs through EIDM account

Help and Support Page

• Click “Help and Support”• Click any button to navigate to that support section (videos, webinars, etc.)

Collapse/Expand

• Click “Collapse” to shrink the side navigation bar for more page real estate• Click “Expand” to return to normal size side navigation bar

CollapsedExpanded

Accessing the Reporting Module

• Click “Account Dashboard”• Click “As a group” or “As individuals” under the REPORT header

• Side navigation shows practice name and TIN when using group reporting• Side navigation also shows clinician name and NPI when using individual

Side Navigation – Group vs Individual

Group Reporting Dashboard

• Click category to report from navigation side bar OR • Click “Start Reporting” button under category name

• Individuals linked to the group TIN will appear under “Connected Clinicians”*• Enter reporting module for each MIPS category by clicking category name

under the REPORT header (next to clinician you are reporting for)

* If clinicians for whom you need to report are missing, they must be linked to the practice/TIN through PECOS at https://pecos.cms.hhs.gov/

Connected Clinicians (Individual Reporting)

Entering Data for MIPS Categories: Quality

Quality – No Existing Data

• Option 1: Upload QRDA or QPP file (self-submission)• Option 2: Contact registry/CEHRT for support with submission on your behalf• Click “File Upload” button to upload your own file

Upload Submission Data

• Click “browse” when the pop-up window appears

Upload Submission Data

• Find the file on your computer and click “Open”

Upload Submission Data

• File(s) will display with option to upload/remove one file at a time or all at once

Upload Submission Data - Errors

• File(s) will display with a status of “Upload Failed”• Click “Upload Failed” to review errors, which can be sent to CEHRT technical

support for analysis to fix issues with QRDA/QPP file formatting

Upload Submission Data - Success

• File(s) will display with a status of “Complete”• Click the “Close” button to exit the upload pop-up window and review

data that was included in the file

Quality – Existing Data

• “File Upload” button still exists to over-write previous upload• “Delete Category Data” button will remove data previously uploaded• Score(s) by submission method display below

Measures that Count

• Scroll down to see summary of submission• System automatically picks best 6 measures that count towards Quality• Each measure will display performance rate and score

Measure Details

• Click the > icon to the left of a measure name to show details

• Displays performance against benchmark and explanation of points earned from decile performance and bonus

Measures with Bonus Points

• Scroll down to see all measures that earned bonus points• Bonus for high-priority/patient experience measures, outcome measures

and/or measures submitted via end-to-end electronic reporting

Measures Submitted but Not Counted

• Scroll down to see all measures included in QRDA/QPP file that were not in the top 6 and do not count towards Quality score

• Can still click > icon to review details on benchmark and points that

would have been earned if the measure were in the top 6

Quality – Additional Submission Methods

• If additional data is uploaded (by you or on your behalf by CEHRT/registry vendor) via another submission method, an additional score will display

• Click “View Details” in the greyed out section to review measures• System will display both but automatically choose your highest score

Entering Data for MIPS Categories: Advancing Care Information

Advancing Care Information – No Existing Data

• Option to use “File Upload” with QRDA/QPP file (same as Quality)• Otherwise, start by selecting your performance period

Select Measure Set

• Each measure set is described• To identify what CEHRT supports, enter keyword in box (optional)• Click “Search” to query products listed on the CHPL

Select Measure Set

• Pop-up window appears with search results• Click the version of the product you used during reporting period

Select Measure Set

• After choosing product, pop-up window will close• Based on CEHRT Edition Year, select from available measure sets

Attestation Statements

• Before entering ACI measure results, you must review and respond to three attestation statements

• Click the > icon to expand and view entire statement• First two statements require agreement (click “Yes”)• Third statement is optional agreement

Enter Measure Data – Base Score

• First section will be measures required for base score• Must enter numerator/denominator or answer Yes/No for all• Pink “thumbs up” icon indicates measure is met

Enter Measure Data – Performance Score

• Next section is Optional Performance Measures• Enter numerator/denominator or answer Yes/No• Performance score points for each measure displays after answering• Category score updates in real time as you add data (pink bar at top)

Enter Measure Data – Bonus Score

• Next section is Additional Registry Bonus• Answer Yes/No to each registry reporting measure• Bonus score points display after answering each question

Enter Measure Data – Improvement Activities Bonus

• Last section is Improvement Activities Bonus• Answer Yes/No to the question• System alerts if you have not attested to any Improvement Activities that

qualify for a bonus, with link to Improvement Activities page• Bonus score points display after answering (“N/A” if no points earned)

Entering Data for MIPS Categories: Improvement Activities

Improvement Activities – No Existing Data

• Option to use “File Upload” with QRDA/QPP file (same as other categories)• Otherwise, start by selecting your performance period• Performance period must be at least 90 days to earn any points

Search for Activities

• Click “Filters” to filter by sub categories, weight or CEHRT bonus eligible• Enter search terms to filter by keyword

Advancing Care Information – CEHRT Version

• Click “Yes” to select activity (turns into green check mark)• Category points will update after selection, with “Category Success” noted

in upper right when reaching maximum score

Additional Considerations and References

Additional Considerations

• There is no “submit” or “save” button anywhere on the QPP submission site

• Data can be added/deleted/updated until window closes on 3/31

• CMS will automatically accept data resulting in the best score

• Same website will be used to show final scores, comparison against national results, and payment adjustments (scheduled for summer)

Additional Considerations

• Quality• Download/request QRDA file from your CEHRT vendor and test upload• Data submitted via claims or CMS Web Interface will not display(?)• Data submitted by ACO will not display(?)

• Advancing Care Information• Download/request QRDA file (upload) or ACI report (manual attestation)

from your CEHRT vendor• Only required category for ACO practices to self-submit (report as a group)

• Improvement Activities• Download/request QRDA file (upload) or IA report (manual attestation) from

your CEHRT vendor; or document which IA you met in advance• System is scoring incorrectly for small practices

• Should score medium-weight = 20, high-weight = 40• CMS has assured this will be fixed/scored correctly

References

• https://youtu.be/q0Cvke6fnrg

Quality Payment Program of Illinois

http://qpp-il.org

info@qpp-il.org

844-QPP-DESK (844-777-3375)

THANK YOU!!