The 2021 performance year of the Merit-based Incentive Payment System (MIPS) is drawing to a close. Here is checklist to keep you on track before CMS opens the data submission period in first quarter 2022.
- Know your MIPS eligibility status for the 2021 performance period, which runs from January 1-December 31, 2021, but for which CMS uses two determination segments to determine final eligibility status. Segment 1 covers October 1, 2019–September 30, 2020 and determines your initial MIPS eligibility. Segment 2 covers October 1, 2020–September 30, 2021 and determines your final eligibility. Segments 1 and 2 are reconciled and this determination is final unless you are identified as a Qualifying APM participant.
To look up your initial MIPS eligibility status on CMS’ QPP website select here. All you need is your NPI and two minutes. Make sure you are checking your status for the 2021 performance year. Final MIPS eligibility will be available in the look up tool in late November or early December. If you are not eligible in Segment 1, you cannot become eligible based on Segment 2.
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Determine your strategy to earn at least 60 achievement points by reporting into MIPS performance categories. A final score of 60 is needed to receive a neutral payment adjustment. A final score below 60 will result in negative payment adjustments on your 2023 claims. Scores above 60 will result in positive payment adjustments.
- Keep in mind you can report into the Quality performance category via multiple mechanisms and CMS will pick the six measures that score highest amongst all those measures reported to determine your Quality score.
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Don’t forget the Improvement Activities performance category. This performance category is weighted at 15% of your total MIPS score so a clinician or group can earn up to 15 points by attesting to having completed improvement activities recognized by CMS as MIPS improvement activities. Download a list of MIPS improvement activities from the Resource Library on the QPP website. You can filter the list of resource documents by choosing Performance Year: 2021, QPP Track: MIPS, and Performance Category: Improvement Activities. The 2021 MIPS Data Validation Criteria file is a good resource. It provides direction on supporting documentation that must be maintained by reporting eligible clinicians for six years, should they be audited.
Each improvement activity must have taken place over a minimum of 90 days within the performance year. The following ASGE programs are recognized by CMS as MIPS improvement activities.
- Achieving and maintaining honoree status in the ASGE Endoscopy Unit Recognition Program meets the criteria for the medium-weighted improvement activity IA_PSPA_18: Measurement and improvement at the practice and panel level.
- Participating in ASGE’s GI Operations Benchmarking meets the criteria for the medium-weighted improvement activity IA_PSPA_17: Implementation of analytic capabilities to manage total cost of care for practice population.
- Participating in ASGE’s Skills Training Assessment Reinforcement (STAR) Certificate Program meets the criteria for the medium-weighted improvement activity IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program To see upcoming STAR course select here.
- CMS lists various improvement activities for leveraging participation in a qualified clinical data registry (QCDR). The GIQuIC registry, sponsored by ASGE and the American College of Gastroenterology, is recognized by CMS as a QCDR.
- Know if you are required to report the Promoting Interoperability performance category. This performance category is worth 25% of your final score, if you are required to submit data for it. When you look up your initial MIPS eligibility status on CMS’ QPP website (here) and expand the details, you will see if you have an automatic exception for reporting this performance category. Most GIs do not. If you are required to report and are not able, apply for a Promoting Interoperability Hardship Exception well before the deadline of December 31, 2021. If you are reporting to this performance category, download a list of promoting interoperability measures from the Resource Library on the QPP website. You can filter the list of resource document by choosing Performance Year: 2021, QPP Track: MIPS, and Performance Category: Promoting Interoperability. Here again, the 2021 MIPS Data Validation Criteria file is a good resource as it is for the Improvement Activities performance categories. The file is multi-tab.
- Consider applying for an Extreme and Uncontrollable Circumstances Exception Application (EUC). If your reporting to one, two, three, or all four MIPS performance categories may not be reflective of your actual performance due to the public health emergency or a natural disaster that interrupted services, apply for an EUC well before the deadline of December 31, 2021. You will want to know if your application is successful.
For detailed information on reporting to the Quality Payment Program and MIPS visit qpp.cms.gov.