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.
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 that will start two years post the close of the current reporting year.
Eligible providers who provide clinical care and bill under Medicare Part B FFS (Fee-For-Service) can participate in MIPS through the QCDR. MIPS-eligible providers include but are not limited to physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. Providers 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 the 2022 MIPS reporting year. 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 providers to track patients and diseases and foster improvement in the quality of care provided to patients.
Eligible providers who are actively submitting their patient data to the registries can request we report their 2022 MIPS data on their behalf. Providers 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 providers’ or groups’ behalf. Only data for eligible providers will be submitted to CMS if the eligible provider and/or group completes an eDRCF by the specified deadline.
Providers must complete the following steps before MIPS data can be submitted by the PINNACLE Registry and Diabetes Collaborative Registry QCDR:
For more information, existing registry participants should contact the Clinical Data Registries support team at firstname.lastname@example.org or 1-833-644-7466.
Yes, a practice may request that the QCDR submit MIPS data on behalf of all providers in the practice. These providers must be listed as active providers in the Provider Profile page. If a practice is reporting their providers as individuals, each individual provider must complete his/her own eDRCF for MIPS data submission. Not all providers are required to report. Not all providers are required to report. To determine if reporting is required, check the provider’s participation status on the QPP website providers
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 are not required to report quality data through the CMS Web Interface. While the APP is required for all Shared Savings Program ACOs, MIPS eligible providers 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 that CMS has extended the CMS Web Interface for use in 2022.
Practices of two or more eligible providers can participate as a group. Group reporting is when performance data for all providers in the practice is aggregated at the Tax Identification Number (TIN) level. All providers 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 providers who are not required to participate because they do not exceed the low-volume threshold will receive a payment adjustment.
The PINNACLE Registry and the Diabetes Collaborative Registry QCDR can accommodate group reporting. Practices are required to notify their dedicated Client Account Manager and the Clinical Data Registry support team of their desire to report as a group by November 1 of the performance year.
The reporting requirements for group reporting are the same as those for individual reporting. Groups 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. 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.
If a provider or group elects to submit data to CMS using the PINNACLE Registry or the Diabetes Collaborative Registry 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 2022 CMS-approved quality measures can be found here.
Patient encounters that occurred between Jan. 1, 2022 and Dec. 31, 2022. Eligible providers and groups are required to report a full year of quality data in 2022.
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 provider 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 providers 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 providers and groups will select their own measures and activities for submission. We offer several resources to review performance prior to submission, including monthly feedback performance reports (available on the Physician Dashboard) that detail adherence to clinical measures across all patient encounters that meet inclusion criteria. Contact your Client Account Manager for assistance navigating the Physician Dashboard.
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 2022 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. Veradigm cannot guarantee performance outcomes.
Providers and practices will receive their final performance feedback reports by logging into the CMS QPP Portal using their HARP account credentials.