“We used two EHRs that were designed backwards – technology first, doctor second.  Amazing Charts is the opposite: incredibly easy to use and clearly designed by a physician.” 

— Peter Sundwall Jr., MD, Family Medicine 

 

 Helpful Documents

Following the "Test" Path: Avoiding a Negative Adjustment (PDF)

Reporting Quality Measures via Claims (PDF)

Prepare for MIPS with the Checklist (PDF)        

  Answers to Your Most Common MIPS Questions 

 

 

General Questions 

Is Amazing Charts ready for MIPS for 2017?

Do I need to upgrade my version of Amazing Charts for 2017 MIPS reporting?

Will Amazing Charts be ready for MIPS in 2018 as well?

Do I have to participate in MIPS?

What are the general requirements for MIPS in 2017?

Do I have to report on all three categories for the same reporting period?

How do I determine the exact adjustment percentage I’ll get in 2019?

Do I have to report as a group or an individual?

Do negative/positive adjustments only affect the provider or stay within a practice?

Do I still need to report for Meaningful Use?

Where do I go to get up to date information on MIPS?

         

Advancing Care Information

How does the Advancing Care Information category work?

Can I use the Meaningful Use Wizard for tracking the Advancing Care Information measures?

Can I still use the Meaningful Use Wizard if I’m reporting as a group?

 

Quality Measures 

What do I have to do for the quality measures category?

Is Amazing Charts adding more quality measures?

What should I do for 2017 for the Quality Measures category if you aren’t updating the quality measures in Amazing Charts yet?

How does scoring work on quality measures in the MIPS program?

How do the quality measure benchmarks work?

Is there a list of quality measures by specialty? How do I choose which measures to report on?

What if the measure set has more than/less than six measures in it?

How do I submit claims so they are counted by Medicare toward my MIPS numbers?

How does CAHPS factor in to all of this?

What's the difference between a Qualified Clinical Data Registry (QCDR) and a Qualified Registry?

 

Improvement Activities 

What do I have to do in 2017 for the Improvement Activities category?

Do I have to do one, two, three or four improvement activities?


 

 

 

General Questions

Is Amazing Charts ready for MIPS for 2017?

Yes!

 

Do I need to upgrade my version of Amazing Charts for 2017 MIPS reporting?

Amazing Charts is currently 2014 Certified Technology and can be used for MIPS reporting in 2017.

However, if you are on a version below Version 9.0 of Amazing Charts, we strongly recommend you update to Version 9.3, which includes a number of bug fixes that will be beneficial to your practices and for MIPS reporting. If you are on a version of Amazing Charts below Version 9.0, and you contact Amazing Charts Customer Support with questions regarding MIPS, they will suggest you to update to Version 9.3; please update now so you are prepared for 2017 reporting. 

Please see our Release Notes about these versions to review all the new features and bug fixes that have been introduced. Make an appointment to upgrade or ask questions by emailing support@amazingcharts.com.

 

Will Amazing Charts be ready for MIPS in 2018 as well?

Yes. You are required to be on a specific certified technology in 2018. We will be planning for this certified technology, Version 10, to be available in late 2017.

 

Do I have to participate in MIPS?

For 2017 and 2018, the following clinicians are eligible for MIPS and therefore would be affected by payment adjustments for their participation or non-participation in MIPS:

  • Physicians
  • PAs
  • NPs
  • Clinical Nurse Specialists 
  • Certified Registered Nurse Anesthetists

  The following clinicians are exempt from participating in MIPS

  • People in their first year of Medicare Part B participation
  • People below the low patient volume threshold: those $30,000 or less in Medicare billing charges or provide care for 100 or fewer Medicare patients in a year. (The low-volume threshold is determined at the individual level for individual reporting and at the group level for group reporting. A clinician's eligibility can change based individual/group reporting method.) CMS looks at Low Volume Threshold Assessment Period from September 1st, 2015 through August 31st, 2016. If a provider falls below either $30,000 billed to Medicare in allowable charges OR below 100 individual Medicare Part B patients seen during that assessment period, they will be notifying providers via letter by the end of March 2017 that the provider is exempt for 2017 reporting.
  • Certain participants in Advanced Alternative Payment Models. (Physicians who provide care to Medicare patients through a recognized Advanced APM will be eligible for a 5% bonus payment. Learn more about Advanced APMs at https://qpp.cms.gov/learn/apms.)

(MIPS does not apply to hospitals or facilities. If a hospital or facility is doing Part A billing (generally for inpatient services), they are exempt - If they bill Part B, they are included.)

 

What are the general requirements for MIPS in 2017?

Your 2019 Medicare payments adjustment will be based on what you report on in 2017.

For 2017, you can avoid any negative adjustment by reporting under the “Test” option. You can earn a positive adjustment on your 2019 by participating in the “Partial” or “Full” option for MIPS.

Test: Under the test option, you would have to do the following:

  •  Report on 1 Quality Measure over any time period
    OR
  • Report on one Improvement Activities for 90 days
    OR
  • Report on just the base Advancing Care Information measures over any time period

Want to avoid the 2019 penalty and nothing more? Follow the MIPS Test Path in 2017.

Partial: Under the partial option, you can earn a small positive adjustment (depending on the number of overall points you earn) by doing the following over a 90 day to full year period:

  • Report on 2 or more Quality Measures
    AND/OR
  • Report one two or more Improvement Activities
    AND/OR
  • Report on the base Advancing Care Information measures as well as enough performance Advancing Care Information measures.

Full: Under the full option, you can earn a larger positive adjustment (depending on the number of overall points you earn) by doing the following over a 90 day to full year period:

  • Report on all 6 Quality Measures or a Quality Measures set
    AND
  • Report two to four Improvement Activities (depending on your practice size/geography) 
    AND
  • Report on the base Advancing Care Information measures as well as enough performance Advancing Care Information measures.

Note: The cost category will be calculated in 2017, but will not be used to determine your payment adjustment.

 

Do I have to report on all three categories for the same reporting period?

For 2017, no. For further flexibility and ease of reporting the 90-day period can differ across performance categories. For example, a MIPS eligible clinician may utilize a 90-day period that spans from June 1, 2017 – August 30, 2017 for the Improvement Activities performance category and could use a different 90-day period for the quality performance category, such as August 15, 2017 – November 13, 2017.

 

How do I determine the exact adjustment percentage I’ll get in 2019?

Unfortunately, this is hard to do. The following explains why.

What we know, based on the information published in the final rule, is that you can get between a 4% decrease in your Medicare payments, or a 4% increase, depending on the data you submit and your performance in 2017.

You can earn up to 100 total points for your MIPS score. 60 of those points can come from the Quality Measure category. 25 of those points can come from the Advancing Care Information category. The final 15 points can come from the Improvement Activities.

  • Less the 3 points: If you earn less than 3 points (AKA you don’t participate in MIPS), you’ll have a 4% decrease on your Medicare payments in 2019.
  • Exactly 3 points: If you earn exactly 3 points, you’ll be able to avoid the negative payment adjustment. You won’t get any positive adjustment.
  • Exactly 100 points: If you earn 100 points, you’ll get the highest possible adjustment, which would include both the 4% positive adjustment on your 2019 payments, plus a possible addition “exceptional performance” adjustment.
  • Between 4 and 99 points: This is where it gets a little complicated. If you earn between 4 and 99 points, you’ll be eligible for between a 0% and 4% payment adjustment increase. There is no table that maps the number of points you get to the adjustment you earn. MIPS/MACRA is a budget-neutral program – the positive adjustments must equal the negative ones. And because the threshold for avoid a negative adjustment is so low in 2017 (3 points), there will likely be fewer people who get a negative adjustment (and therefore a small amount of money to pass out across those who each more than 3 points). We do know he more points you get, the better your chance at a higher payment adjustment.

 

Do I have to report as a group or an individual?

It’s up to you. If you report as a group, you have to report all categories as a group. The same goes if you report as an individual.

Individual

If you send MIPS data in as an individual, your payment adjustment will be based on your performance. An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number. You’ll send your individual data for each of the MIPS categories through an electronic health record, qualified registry, or a qualified clinical data registry. You may also send in quality data through your routine Medicare Part B claims process.

Group

If you send your MIPS data with a group, the group will get one payment adjustment based on the group’s performance. A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site. Your group will send in group-level data for each of the MIPS categories through the CMS web interface or an electronic health record, qualified registry, or a qualified clinical data registry. (To submit data through the CMS web interface, you must register as a group by June 30, 2017.)

 

Do negative/positive adjustments only affect the provider or stay within a practice?

You will be submitting your data alongside a TIN (Tax Identification Number). If you report as an individual under an individual TIN, the adjustments will follow that TIN. If you report as a group under a group TIN, the adjustment will follow that group of people.

Your payments in 2019 will be decreased or increased by the percentage you earn based on the 2017 data you submit.


Do I still need to report for Meaningful Use?

In 2017, if you're eligible for MIPS, you will participate in that. MIPS has taken the place of MU for Medicare Part B providers. Please note that if you still qualify for the Medicaid Meaningful Use program (or the hospital-based Medicare Meaningful Use program), you will still need to report for that program in 2017. 

 

Where do I go to get up to date information on MIPS?

There is an informative and easy to navigate new website from CMS that has a lot of the information you need: https://qpp.cms.gov/learn/qpp

Also, you can always visit this page of the overview page (http://amazingcharts.com/support/macra-mips) for up-to-date checklists and information.


 

Advancing Care Information in 2017 – 25% of Total Score

How does the Advancing Care Information category work?

Test Path: Under the “Test” path you can choose to report on one of the three scored categories in 2017. If you choose the Advancing Care Information category, you're required to report on the following:

  • Security Risk Analysis: You must complete this analysis and attest “yes” (If you need help completing the Security Risk Analysis, our partner, Emerald Cybersecurity Solutions, may be able to help.)
  • e-Prescribing: The numerator must be at least one  (aka include one prescription). 
  • Provide Patient Access: The numerator must be at least one 
  • Health Information Exchange: The numerator must be at least one 

Follow the MIPS Test Path in 2017.

Partial/Full Path: Under the Partial/Full paths, you can earn up to 100 points. You can earn 50 of those points by reporting for at least 90 days on the following:

  • Security Risk Analysis: Complete and attest “yes”
  • e-Prescribing: Have at least 1 in the numerator
  • Provide Patient Access: Have at least 1 in the numerator.
  • Health Information Exchange: Have at least 1 in the numerator

 You can earn up to 50 more points by reporting on the following

  • Health Information Exchange: Up to 20 points based on percentage
  • Provide Patient Access: Up to 20 points based on percentage
  • Immunization Registry Reporting: Up to 10 points by  attesting “yes”
  • Medication Reconciliation: Up to 10 points based on percentage
  • Patient Specific Education: Up to 10 points based on percentage
  • Secure Messaging: Up to 10 points based on percentage
  •  View, Download, Transmit: Earn up to 10 points based on percentage
  • Syndromic Surveillance: Earn up to 5 points by attesting “yes”

 

Can I use the Meaningful Use Wizard for tracking the Advancing Care Information measures?

Yes! Even better, there are no longer thresholds you have to meet in order to “pass” the program, so all you need to do is run the report and review your numbers.

The new advancing care information measures aren’t numbered like Meaningful Use measures, but you can find them in the Wizard by looking for the correct measure/objective name.

 

Can I still use the Meaningful Use Wizard if I’m reporting as a group?

Yes. Though the Meaningful Use Wizard does not calculate group data, MIPS allows you to aggregate data adding together the numerators and denominators calculated for each MIPS-eligible clinician in Amazing Charts (even though know that this may cause “unique patients” to be counted more than once in the denominator and numerator).

Note that if an individual MIPS eligible clinician in that group meets the criteria to exclude a measure, their data can be excluded from the calculation of that particular measure only.

 


 

Quality Measures in 2017 – 60% of Total Score

What do I have to do for the Quality measures category?

What you have to do depends on which path you take:

  • Test - Under the “test” option, you can report on 1 Quality Measure over any time period in 2017. (Though, you can also skip this category and choose to report on the four base measures or one improvement activity instead.) Want to avoid the 2019 penalty and nothing more? Follow the MIPS Test Path in 2017.
  • Partial - Under the “partial” option, you can report on 2 or more Quality Measures over a 90 day to full year period. (Though, you can also choose to skip this category if you don’t want the 60 possible points).
  • Full - Under the “full” option, you must report on 6 quality measures (or a measure set) over a 90 day to full year period. (The Quality Payment Program support desk tells us it will be hard on some measures to earn the full 10 points if you only report on 90 days, so they recommend if you’re interested in going for all 10 points that you report for a full year.)

 

Is Amazing Charts adding more quality measures?

Yes, in Version 10. Version 10 of Amazing Charts, which will be certified for use in the 2018 MIPS program, will include more (and more relevant) measures than currently offered in Amazing Charts. Version 10 will be out in late 2017.

 

What should I do for 2017 for the Quality Measures category if you aren’t updating the quality measures in Amazing Charts yet?

For 2017, what you do depends on which path you want to take.

For the 2017 reporting year, if you want to complete the “Test” or “Partial” path, or earn 3 points per measure (see the scoring question if you haven’t reviewed that information yet), we recommend you continue working like you normally do, and update to Version 10 when it is released in Q4 2017. In Version 10, you will be able to run reports on quality measures. A full list of what we will offer in Version 10 will be available at a later date.

If you want to go for the “Full” path or try to earn the full 10 points for quality measures you submit, we suggest pairing with a qualified registry or QCDR, or do Medicare Part B claims-based reporting, to track and report quality measures. Learn more about how claims-based reporting worked for PQRS; it will be similar for MIPS.

Note that some registries and QCDRs are automatic and some are manual. For manual entry, like with PQRSwizard that was used for PQRS, you may have to keep track of patients by hand, and fill out forms about those patients, then enter that data into the QCDR/registry system. Automatic entry generally means the QCDR pulls data from your database automatically instead of you having to enter it. You can ask your registry/QCDR what kind of system they have, and review the Quality Category webinar for more detailed information. 

PRIME (and the rest of the FIGmd registries), PQRSwizard and MDinteractive have all been used by Amazing Charts users for other quality measures programs. The ABFM suggests using the PRIME registry, which extracts data automatically directly from the Amazing Charts database. The AAFP suggests using the PQRSwizard registry, which requires manual entry of data, and which the organization reports will be ready for MIPS. Providers should research the options, talk to their professional organizations, and choose what works for them. You can find a full list of the 2016 qualified registries here. You can connect with these registries to determine if they are reporting for MIPS. When we have an updated list on registries and QCDRs for 2017, we will update this link.

 

How does scoring work on the quality measures in the MIPS program?

MIPS quality measure scoring works differently from the PQRS quality measure scoring. PQRS was a pay-for-reporting program. MIPS is a pay-for-performance program. That means that you earn points on measures for how well you do on them.

You can earn a maximum of 10 points per measure.

In 2017, they have decided to give a number of points per measure just for reporting it: for each measure you submit, you get an automatic 3 points.

The other 7 points can be earned only if the measure has a benchmark to measure your performance against and if the following is satisfied:

  • Data Completeness Required: If you’re reporting on quality measures via a QCDR, a qualified registry, or EHR, you need to report on at least 50 percent of the MIPS eligible clinician or group’s patients that meet the measure’s denominator criteria, regardless of their payer (both Medicare and non-Medicare patients). If you’re reporting via claims, you need to report on at least 50% of the Medicare Part B patient seen during the performance period. In 2017, if you don’t follow this requirement for a measure, you’ll receive the minimum score of 3 points for that measure.
  • Case Minimums Required: To qualify for more than 3 points per measures, you are required to have a minimum of 20 cases per measure.

Once you meet those requirements, you will be scored based on a decile system.

Note: If you have 0 in the denominator for a measure in 2017, report them anyway. You’ll receive the minimum of 3 points.

 

How do I use the benchmarks that CMS published? 

CMS published the benchmarks for Quality measures at the end of December. You can find the packet of information here.

In the packet, you'll find a spreadsheet with all of the quality measures that have a benchmark. You'll be able to see in this spreadsheets that the benchmark (and the points you achieve for the percentage you report) varies by your submission method. Benchmarks do not vary by location or geography.

Let's take Diabetes: Hemoglobin A1c Poor Control (Measure ID 1) as our first example. Let's suppose you're reporting on this quality measure via a Registry/QCDR (instead of via claims or an EHR, which have separate benchmarks). 

Below, we've repeated the deciles from the spreadsheet. We've added the points associated with each decile. Note that Decile 1 and Decile 2 are not included because CMS is allowing any measures scoring in those percentages to receive 3 points for 2017.

Decile 3:   35.00 - 25.72%  --  Earn 3 to 3.9 points
Decile 4:   25.71 - 20.32%  --  Earn 4 to 4.9 points
Decile 5:   20.31 - 16.23%  --  Earn 5 to 5.9 points
Decile 6:   16.22 - 13.05%  --  Earn 6 to 6.9 points
Decile 7:   13.04 - 10.01%  --  Earn 7 to 7.9 points
Decile 8:   10.00  -  7.42%  --  Earn 8 to 8.9 points
Decile 9:    7.41   -  4.01%  --  Earn 9 to 9.9 points
Decile 10:             <4.00%  --  Earn 10 points

Also note that this example uses a reversed quality measure -- the lower the percentage, the better you did on the measure and the more points you'll earn and many registries and QCDRs plan to display these benchmarks within their portals so you can easily see how you are faring.

Benchmarks are based on different data depending on the method of submission you use. You'll notice that there are some measures in the spreadsheet that are marked as not having a benchmark. For those measures, if more than 20 clinicians submit the measure in 2017 (and each of those clinicians meet the data completeness and case minimums for that measure), then your percentage will be judged against the benchmark that the 20 or more clinicians create. If fewer than 20 clinicians meeting those requirements report on the measure in 2017, you'll still be able to receive the 3 points just for submitting the measure (though this will likely change in 2018).


Yes. On the Quality Payment Program website, there is a list of all the possible quality measures you can report on in 2017. You can filter by specialty. See the list here.

Note that just because the measure is on the list doesn’t mean a registry will include that in their offering. If you are a specialist and you’re looking to go the “full” reporting route and seek the full 10 points per measure, speak to your professional organization about the registry you should use.

Make sure to remember that you’re required to report on at least one outcome measures (or if no outcome measures apply to you, a high priority measure). To maximize your point-earning capability, review the question below about earning points.


What if the measure set has more than/less than six measures in it?

If the measure set has more than 6 measures, you can choose 6 to report on. If the measures set has less than 6 measures, you must report on all the measures in the set (but you do not need to pick additional measures to reach six).


How do I submit claims so they are counted by Medicare toward my MIPS numbers?

The codes included in you claim will mark a patient as part of the denominator and/or numerator. Once you choose the measures you want, find them in the list of specifications and determine the codes you need to add to your claims. If you're doing the "Test" path, you only need to submit one claim in which the patient is in the numerator--this allows you to avoid the 2019 penalty. If you're doing the "Full" or "Partial" paths, you'd earn 3 points per measure you include codes for, and more than 3 points if you meet the data completeness requirements.


How quickly must Medicare Part B claims be submitted if I’m using them to turn in data for Quality Measures?

For Medicare Part B claims, data must be submitted on claims with dates of service during the performance period that must be processed no later than 60 days following the close of the performance period.

 

How does CAHPS factor in to all of this?

CAPHS is reportable for groups in the MIPS program. For the 12-month performance period, a group that wishes to participate in the CAHPS for MIPS survey measures must use a survey vendor that is approved by CMS for a particular performance period to transmit survey measures data to CMS. The CAHPS for MIPS survey counts for one measure towards the MIPS Quality performance category and, as a patient experience measure, also fulfills the requirement to report at least one high priority measure in the absence of an applicable outcome measure. Groups that elect this data submission mechanism must select an additional group data submission mechanism in order to meet the data submission criteria for the MIPS quality performance category.


What's the difference between a QCDR and a registry?

CMS defines a Qualified Registry as "an entity that collects clinical data from an EP or PQRS group practice and submits it to CMS on behalf of the participants." It defines a Qualified Clinical Data Registry (QCDR) as a "CMS-approved entity that collect medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients." Basically, QCDRs are the registry of the future, and often include additional quality measures created in conjunction with specialty organizations; these measures can also be reported for the MIPS program. CMS recommends using a QCDR.


 

Improvement Activities – 15% of Total Score

What do I have to do in 2017 for the Improvement Activities catgegory?

What you have to do depends on which path you take:

  • Test - Under the “test” option, you can report on 1 Improvement Activity over any time period in 2017. (Though, you can also skip this category and choose to report on the four base measures or one quality measure instead.) Want to avoid the 2019 penalty and nothing more? Follow the MIPS Test Path in 2017.
  • Partial - Under the “partial” option, you can report on 2 or more Improvement Activities over a 90 day to full year period. (Though, you can also choose to skip this category if you don’t want the 15 points).
  • Full - Under the “full” option, you must report on 2 to 4 improvement activities (depending on your practice size/geography) over a 90 day to full year period.

 

Do I have to do one, two, three or four improvement activities?

If you are a small practice (1-15 practitioners), a non-patient facing MIPS eligible clinician/group, or a practices located in rural areas and geographic HPSAs, you only have to complete 20 points worth of activities. Other clinicians that do not fall in those categories have to complete 40 points worth of activities.

Improvement Activities are worth either 10 points, for medium activities, or 20 points, for high activities. You will receive full credit for the improvement activities performance category in 2017 if:

  • You are a MIPS eligible clinician or group that has received certification or accreditation as a patient-centered medical home or comparable specialty practice from a national program or from a regional or state program, private payer or other body that administers patient-centered medical home accreditation and certifies 500 or more practices for patient-centered medical home accreditation or comparable specialty practice certification.
  • If you are an Advance APM Medical Home Model (As of November 1, 2016, the only “Medical Home Model” identified by CMS that meets the qualifications below is the Comprehensive Primary Care Plus (CPC+): Has a primary care focus, offers primary care services with patients empaneled to a primary clinician, and meets other necessary requirements.)

 


 Was your question not answered here? Send an email to Amazing Charts Client Services with your question at support@amazingcharts.com.