MIPS Frequently Asked Questions

The following information is provided for educational purposes only and should not be regarded as clinical or legal advice. Veradigm does not ensure the accuracy of this information and does not guarantee that following this information will result in receiving any government payment. It is the attesting healthcare providers responsibility to comply with all program requirements.

Using the PINNACLE and Diabetes Collaborative QCDR for Merit-Based Incentive Payment System (MIPS) Program

General MIPS Inquiries

The Merit-based Incentive Payment System (MIPS) is one of two tracks offered by CMS to meet the requirements of the Quality Payment Program (QPP). MIPS is a single program that replaces PQRS, EHR Incentive Program (Meaningful Use) and the Value-Based Modifier. Practices will earn a payment adjustment based on four performance categories: Quality, Improvement Activities, Promoting Interoperability and Cost. Each component is a weighted score that will contribute to the overall payment adjustment in 2023 for participation in the 2021 QPP program year.

Eligible clinicians who provide clinical care and bill under Medicare Part B FFS (Fee-For-Service) can participate in MIPS through the QCDR. MIPS-eligible clinicians include but are not limited to physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. Clinicians can enter their 10-digit National Provider Identifier (NPI) number on the CMS website to view their QPP participation status by performance year.

The registries are an approved single QCDR reporting option for MIPS 2021. A QCDR is defined as a CMS-approved entity that has successfully completed a rigorous qualification process and demonstrates clinical expertise in medicine and quality measurement development that collect medical or clinical data on behalf of MIPS eligible clinicians to track patients and diseases and foster improvement in the quality of care provided to patients.

Eligible clinicians who are actively submitting their patient data to the registries can request we report their 2021 MIPS data on their behalf. To initiate this, clinicians must complete an electronic data release consent form (eDRCF). The eDRCF provides consent required by CMS that allows the QCDR to release data to CMS on the clinicians’ or groups’ behalf. Only data for eligible clinicians will be submitted to CMS if the eligible provider and/or group completes an eDRCF by the specified deadline.

Providers must complete the following three steps before 2021 MIPS data can be submitted by the PINNACLE and Diabetes Collaborative QCDR:

  • Practices must contract with either the PINNACLE Registry or the Diabetes Collaborative Registry by Sep. 3, 2021
  • Practices must be actively submitting data to the registries through their EHR system integration by Nov. 1, 2021 and
  • Completion of an eDRCF for clinician(s) and/or group is required

For more information, existing registry participants should contact their dedicated Client Account Manager or the Clinical Data Registries support team at registries@veradigm.com or 1-833-644-7466.

Yes, a practice may request that the QCDR submit MIPS data on behalf of all clinicians in the practice. If a practice is reporting their clinicians as individuals, each individual provider must complete his/her own eDRCF for MIPS data submission. All clinicians at a given practice are not required to participate in the QCDR for MIPS reporting.

Shared Savings Program ACOs will be automatically registered for the CMS Web Interface. Shared Savings Program ACOs are required to report under the APP but aren’t required to report quality data through the CMS Web Interface. While the APP is required for all Shared Savings Program ACOs, MIPS eligible clinicians participating in those ACOs have the option to report through the APP outside of the ACO or participate in MIPS outside of the APP at the individual or group level.

Please note, this is the last year the CMS Web Interface will be available for quality measure reporting.

Group Practice Reporting for MIPS 2021

In 2021, practices of two or more eligible clinicians can participate as a group practice. Group practice level reporting (GPRO) is when performance data for all clinicians in the practice is aggregated at the Tax Identification Number (TIN) level. All clinicians under the TIN will receive the same score. Solo practitioners are not eligible to report as a group.

If a practice chooses to participate as a group, individual clinicians who aren’t required to participate because they do not exceed the low-volume threshold will receive a payment adjustment.

The PINNACLE and the Diabetes Collaborative QCDR can accommodate GPRO reporting. Practices should notify their dedicated Client Account Manager of their desire for GPRO reporting ahead of the CMS deadline.

The reporting requirements for GPRO are the same as those for individual reporting. Group practices must submit six quality measures, including one outcome measure or one high-priority measure and report for at least 70 percent of the group practice’s patients. In order to successfully report data for Improvement Activities, at least 50% of the providers within the group must participate in that activity during any continuous 90-day period in the performance year.

Simply reach out to your dedicated FIGmd client account manager to inform them your practice is reporting as a group.

Note: for group practice reporting, you only need to complete one eDRCF per TIN.

Data Submission for MIPS 2021

If a provider or group elects to submit data to CMS using the PINNACLE or the Diabetes Collaborative QCDR, Veradigm will provide CMS with Quality measures, Improvement Activities and Promoting Interoperability measures selected by the practice as long as they meet each performance category requirement. Practices will select their own measures and activities for submission via the Physician Dashboard.

A listing of the 2021 CMS-approved MIPS measures can be found here. Detailed specifications for non-MIPS (QCDR) measures also are available here.

Patient encounters that occurred between Jan. 1, 2021 and Dec. 31, 2021. Eligible clinicians and groups are required to report a full year of quality data in 2021.

Practices are required to submit 100 percent of patient encounters that meet inclusion criteria. Generally, that includes face-to-face office visits for patients with coronary artery disease, heart failure, hypertension, diabetes and/or atrial fibrillation.

No, participation in registry data collection requires providers and practices to submit all data elements on all patients that meet the inclusion criteria, regardless of payer status, not just the select MIPS measures.

A MIPS eligible clinician or group may submit MIPS data through multiple submission methods. Each reporting mechanism must encompass a complete reporting period and include the minimum reporting requirements. There are two exceptions specific to quality reporting, CMS Web Interface which can only be used by groups, virtual groups of at least 25 clinicians and ACOs and claims can only be used by those with a small practice designation.

Promoting Interoperability: Any conflicting data for a single measure or required attestation submitted through multiple submission types will result in a score of 0 for the Promoting Interoperability performance category.

No, CMS does not allow the combining of incomplete submissions to meet the MIPS requirements.

Yes, eligible clinicians and groups will select their own measures and activities for submission. If you decide to report using the PINNACLE or the Diabetes Collaborative QCDR, there are several available resources to review your performance, including monthly feedback performance reports that detail adherence to clinical measures across all patient encounters that meet inclusion criteria. talk to your Client Account Manager to help you use the Physician Dashboard to gauge performance.

We have also provided a crosswalk of MIPS measures with the standard registry measures, where applicable. You can also review your performance at the group or individual provider level via the Physician Dashboard. If you have questions regarding your measure performance, contact your Client Account Manager immediately.

NOTE: Regular monitoring of your data via the Physician Dashboard is required. Practices can use to use the monthly performance reports to gauge their likelihood of meeting 2021 MIPS requirements. Practices also can use the MIPS Dashboard within the Physician Dashboard to gauge their performance in each performance category and review their preliminary scores.

CMS is responsible for all payment and adjustment determinations. Neither Veradigm nor the ACC can guarantee performance outcomes.

Clinicians and practices will receive their feedback and scores by logging into the CMS QPP Portal using their HARP account credentials.

For more information about the Pinnacle and Diabetes registries

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