CMS Quality Payment Program: MIPS Reporting for 2023

The Medicare Merit-Based Incentive Program System (MIPS) came about as part of the U.S. Government’s Sustainable Growth Initiative (SGI) in 2016. The program incentivizes providers, practices, and practice groups to render quality and efficient care functional to their overall Medicare reimbursement. This incentive currently offers both positive and negative adjustment factors for meeting - or not meeting - certain performance metrics and reporting requirements. MIPS is generally a requirement for all providers who bill Medicare Part B for professional services, with limited exceptions given certain criteria for hardships or practice volume thresholds. In most circumstances (outside of APM arrangements), the MIPS reporting template for 2023 requires attestation or data across four domains:

1. Quality - 30% of total
2. Promoting Interoperability - 25% of total
3. Improvement Activities - 15% of total
4. Cost - 30% of total

Promoting Interoperability accounts for a significant segment of total score calculation. This percentage is adjustable due to reweighting factors such as hardships, special status designation, or Alternative Payment Model (APM) participation. Promoting Interoperability is a demonstration of a provider or practice’s effective use of Electronic Health Record (EHR) technology to effectively integrate and manage care.

What about waivers?

There are qualified exemptions for 2023 MIPS reporting that will likely carry into future years. These are based on provider type and other circumstances which may impact meaningful reporting. Let’s take a look at these individually. See How MIPS Eligibility is Determined PY 2022 for more information.

1. You are a Clinical Social Worker, Physical Therapist, Occupational Therapist, Qualified Speech Language Pathologist, Qualified Audiologist, Clinical Psychologist, or a Registered Dietitian/Nutrition Professional

These provider types are not required to report Promoting Interoperability data in 2023. For these providers, their PI category will automatically be reweighted. It may be worthwhile to discuss the unique circumstances of these providers’ practice with a MIPS expert, as their supervising medical authority (e.g.: MD/DO) may still be required to report. Generally, CMS evaluates each billing combination of Tax ID Number (TIN) and provider NPI to determine MIPS eligibility for each pair. At a practice level, CMS uses the billing TIN to determine group eligibility.

2. You are a special status facility or practice, such as an Ambulatory Surgical Center (ASC), a hospital-based practice, a non-patient facing practice, or a small practice.

These special statuses are determined by CMS based on analysis of Part B claims data over a twenty-four month period.

Of particular interest to small practices is the CMS Low Volume Threshold exemption rule. The Low Volume exemption is calculated using three distinct data points: Allowed Charges, Number of Medicare patients who receive services, and the number of total services provided. These thresholds are outlined below:

1. Did the practice bill more than $90,000 in Medicare Part B claims in the evaluation period (each twelve month block of billing)?
2. Did the practice complete visits for more than 200 Medicare Part B patients?
3. Did the practice provide more than 200 covered services under Medicare Part B?

These thresholds are collective; therefore they must all be ‘Yes’ in order to be considered not exempt. Consider the following three examples:

Primary Urgent Med has seen 1,000 Medicare Part B patients during the evaluation period. In total, the practice billed over $200,000 in Medicare professional services across more than 6,000 visits. Because the practice has surpassed the thresholds in all three data points, they are not exempt from MIPS reporting based on small practice exclusions.

Dr. John Smith runs a small, independent primary care practice. In a twenty-four month period he saw 135 Medicare Part B patients across 175 visits. In total he billed $120,000 in Part B professional fees. Dr. Smith is exempt because although he billed beyond the threshold, his volume supports exemption.

Great Pediatric Care, Inc. sees approximately 1,500 unique patients in twenty-four months. Of these, only twelve were Medicare-eligible by basis of being a family dependent of a covered patient. Regardless of the billing amount, their volume is far below the threshold and they are exempt from MIPS reporting.

It is very important to validate your exemption status. A miscalculation can result in a severe reduction in total MIPS points and a subsequent reimbursement adjustment of up to -9%. All providers and practices should verify their status at the link below:

https://qpp.cms.gov/participation-lookup

3. Hardships and EHR Availability

There are also exemptions available for particular hardships and lack of EHR technology. See QPP Exception Applications for information on applying for a hardship exemption.

These include:

1. You are a MIPS-eligible clinician using a decertified EHR technology
2. This means your current EHR has lost its certification status with ONC
3. Insufficient internet connection
4. Extreme and Uncontrollable circumstances
5. Note: There were waivers put in place for the COVID-19 Pandemic; it is important to determine if your practice was impacted by these waivers and would therefore qualify for a hardship exemption.
6. A lack of control over the availability of a certified EHR.

If your practice or providers believe they may qualify for an exemption under these hardships, please login to your QPP account and submit an application for a waiver:

https://qpp.cms.gov/login

The flowchart from CMS can be helpful in determining initial eligibility. Remember to always verify your eligibility by checking your QPP status:

Graphic: CMS. “2023 MIPS Eligibility Decision Tree”. 2023. https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2418/2023MIPSEligibilityTree.pdf

Determining your Reporting Pathway

If you are eligible for MIPS reporting and will not seek an exemption, it is critical that you assess your reporting pathway under MIPS. Refer to Participation Options Overview for more detail.

The following three options are available for MIPS-eligible, non-waived practices and providers to report:

1. You will report through traditional MIPS.
2. In this case you will select your own measures to report for quality and improvement activities. You will also need to report on promoting interoperability. Performance data is automatically calculated by CMS. The measure weighting for this pathway is highlighted above.
3. Reporting via an Alternative Payment Model (APM) Performance Pathway.

1. This option is available for providers who participate in a Medicare APM. The measure set for this option is pre-determined and weighting does vary slightly. MIPS APM providers automatically receive full credit for improvement activities in 2023. Confirm with CMS if you are unsure if you can report via this pathway.

    3.  Reporting through MIPS Value Pathways

1. This is a new option for providers and practices to report MIPS as tailored to their specific specialty or conditions which they treat. In this pathway the measures are grouped differently, allowing providers within a specialty to report on pertinent information as opposed to broad, general metrics. Cost and population health measures are automatically calculated by CMS. Confirm with CMS if you are unsure if you can report via this pathway.

You will want to review and select the measures you will report on for MIPS quality. The below tool is helpful in making selections:

Explore Measures & Activities

Reporting

MIPS can be reported via the CMS QPP Interface. The following outline will help you get started. See Reporting Options Overview for more detail on reporting options.

1. Quality: This can be reported in three ways.
2. Uploading a file of data through the CMS QPP Website
3. Working with an intermediary to submit data on your behalf
4. For small practices: you can report quality measurement through your Part B claims throughout the performance year.
5. Improvement: This can be reported two ways.
6. Attest to measures performed via the QPP Website
7. Work with an intermediary to submit data on your behalf
8. Promoting Interoperability: This can be reported two ways.
9. Attest to required data via the QPP Website
10. Work with a third party to submit data for you
11. Cost: This is automatically calculated by CMS

Can Oystehr help me report for MIPS?

Oystehr’s flexibility and API connectivity make it an ideal solution for MIPS reporting. Not only can Oystehr’s team leverage their experience in the healthcare industry to help you with your MIPS questions, they can also work with your technical team to develop API connections and Electronic Data Interchanges with Medicare for data submission on your behalf. In fact, providers are already trusting Oystehr’s team of experts with their 2023 MIPS reporting questions and solutions.

A headless EHR platform is the perfect place to start if you are confused or concerned about your MIPS eligibility or exposure in 2023. The Oystehr team has spent years working with MIPS practices and is standing by to help. The flexibility of Oystehr to adapt and connect to numerous interfaces may even allow an automated data submission directly from your current, ONC-certified EMR.

If you are interested in getting the help you need to avoid up to a 9% reduction in your Medicare reimbursement, contact the Oystehr team today at [email protected]. We look forward to helping you determine your reporting pathway and the best solution for your 2023 MIPS reporting needs.

What about ONC Certification and my EHR or Health Technology?

ONC Certified technology is the core prerequisite for MIPS reporting. Oystehr offers assistance with obtaining ONC Certification for your health technology or potential product. Our team of technical and subject matter specialists will assist you in understanding and fulfilling the requirements for this critical certification.

1. Contact Oystehr - [email protected] or via our Slack channel ‘Oystehr’. The slack channel will give you access to important reference materials around ONC Certification as well as serve as a starting point for your product journey.
2. A member of the Oystehr team will review the ONC Certification criteria with you, and identify metrics which would require recertification if changed. This includes the Maintenance of Certification Requirements listed by HealthIt.Gov:

Conditions & Maintenance of Certification | HealthIT.gov