Specifically, the denominator would include patients seen by the physician (or, in the case of group reporting, by the group as a whole) within the selected 90-day performance period who are 18-85 years of age with a diagnosis of hypertension. The numerator would be those patients whose systolic blood pressure is below 140 mmHg and diastolic blood pressure is above 90 mmHg at the most recent visit during that period. Again, to be reportable, the denominator would have to include at least 20 patients representing at least one-half of the hypertensive adults seen during the performance period.
A complete list of the 271 approved MIPS quality measures, which includes the definition of the denominator and numerator for each measure, is available on the Quality Payment Program website. The QPP website also provides information on the different ways in which a physician or group can report on the measures (e.g., claims, EHR, registry) and the applicable benchmarks for each measure.
Reporting on clinical practice improvement activities
A physician seeking to avoid the 4 percent penalty in 2019 may elect to report on a clinical practice improvement activity instead of a quality measure. In that case, the physician (either individually or as part of a group) would attest to having engaged in one approved activity for at least 90 continuous days during 2017. The activity does not have to be “new;” a physician can take credit for established programs.
The complete list of the 92 activities approved for 2017 also is available on the Quality Payment Program website. The listed activities cover a broad spectrum, from implementing an antibiotic stewardship program to providing ambulatory care management services. The website also provides information on reporting mechanisms.
Another option: The advancing care improvement component
A third option for a physician seeking to avoid the 4 percent penalty is successfully reporting on all of the measures included in the base score for the advancing care improvement (ACI) component, which replaces the MU program for physicians. For 2017, the base score measures include:
(1) Conducting a security risk analysis
(3) Providing patient electronic access
(4) Sending a summary of care
(5) Requesting and accepting a summary of care
The first measure requires a “yes” response, while the other four are reported with a denominator and a numerator of at least one. Because reporting a single quality measure or a single clinical practice improvement activity involves less tracking and compilation of data, we anticipate few physicians will use the ACI route to avoid the 2019 penalty.
Picking up the pace: Pursuing MIPS bonus payments
If a physician has successfully reported performance to PQRS and/or attested to MU in prior years, they may be ready to “pick up the pace” by pursuing MIPS bonus payments. To be eligible for bonus payments, a physician must:
(1) Report on six MIPS quality measures (unless reporting through the GPRO web interface or through a qualified clinical data registry)
(2) Attest to having engaged in four clinical practice improvement activities (or only two activities, if certain conditions are satisfied)
(3) Report on both the ACI base score and performance score measures
If a physician participates in an accountable care organization (ACO) enrolled in Track 1 of the Medicare Shared Savings Program (MSSP), their MIPS reporting requirements are reduced significantly. These physicians only report on the ACI base score and performance score measures; the balance of the MIPS score is based on MSSP performance.
Physicians who elect to report individually using Part B claims will need to include specified codes on those claims at the time of submission for at least a 90-day period during 2017; one cannot add this information to claims at a later time. Groups with 25 or more practitioners that elect to report through the GPRO web interface must register by the end of June 2017. Otherwise, physicians will report on 2017 performance during the first quarter of 2018. Now is the time, however, to develop your MIPS game plan, including “pick your pace,” measures selection, and process improvement to improve performance on selected measures.