1. Hess, Cathy Thomas BSN, RN, CWCN

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As we continue our work in 2020 while moving through the pandemic, we need to stay laser focused on the Merit-based Incentive Payment System (MIPS) as one way to participate in the Quality Payment Program.1 Your performance is evaluated across four categories, shared below, which leads to improved quality and value in our healthcare system. The MIPS performance categories have different "weights," and the scores from each of the categories are added to give you a MIPS Final Score. Following the performance period, if you submit 2020 data for MIPS by March 31, 2021, you will receive a positive, negative, or neutral payment adjustment in the 2022 payment year, based on your MIPS Final Score. As specified in the Medicare Access and CHIP Reauthorization Act of 2015, the positive payment adjustment could be up to +9%, and the maximum negative payment adjustment is up to -9%.


Your MIPS 2020 reporting requirements checklist is as follows:


1. Check your eligibility.


2. Determine if you are reporting as an individual or as a group.


3. Determine your reporting method.


4. Review the changes to performance thresholds, payment adjustment, and reporting categories.


5. Understand the MIPS category requirements and timeframes for each category captured.


6. Align your documentation workflows, maintain your data validation and audit (DVA) folder, and review your MIPS reports early and often.


7. Report your MIPS documentation by March 31, 2021.



Let's unpack each item on the checklist.


The first step in the reporting process is to check your eligibility. Ensure you understand how MIPS eligibility and the low volume threshold are determined for your reporting. Next, determine how you will report (such as a qualified individual or group) and review the eligibility determination periods and snapshots throughout the year. Clinicians continue to need the 2015 Edition of the certified electronic health record technology to report data for the Promoting Interoperability performance category and to report electronic clinical quality measures for the Quality performance category. Equally important is to determine your method of reporting. Reporting can be completed via Electronic Medical Record, Quality Registry, Qualified Clinical Data Registry, or Medicare Part B Claims.


Let's take a look at the performance thresholds, payment adjustments, and the four reporting categories for your use in 2020.


CMS finalized the following performance thresholds and category weights for the 2020 performance period (which equates to the 2022 payment year):


* The performance threshold is 45 points.


* The additional performance threshold for exceptional performance is 85 points.



The Quality performance category assesses the quality of care you deliver based on measures of performance. For the 2020 reporting period, the Quality performance category is weighted at 45% (no change from Payment Year [PY] 2019) and is collected over a full year. The following additional updates were included:


* increased data completeness threshold to 70%,


* continued to remove low-bar, standard of care, process measures,


* addressed benchmarking for certain measures to avoid potentially incentivizing inappropriate treatment,


* focused on high-priority outcome measures, and


* added new specialty sets (Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietitian, and Endocrinology).



The Cost performance category assesses the cost of the care you provide based on your Medicare claims. Cost measures are also used to gauge the total cost of patient care during the year or a hospital stay. The Cost performance category is weighted at 15% (no change from PY 2019). Cost measures are evaluated automatically through administrative claims data and you do not need to submit data. Additional updates include the following:


* 10 new episode-based measures to continue expanding access to this performance category; and


* revision of the existing Medicare Spending per Beneficiary Clinician and Total per Capita Cost measures.



The Improvement Activities performance category assesses your participation in clinical activities that support improvement and patient engagement, care coordination, and patient safety. This performance category is weighted at 15% (no change from PY 2019). Clinicians must attest to activities for a consecutive 90-day reporting period. To receive full credit for this category, small practices must attest to one high-weighted or two medium-weight activities. Large practices (16 or more clinicians) must report more activities:


* two high-weighted activities; or


* one high-weighted activity and two medium-weighted activities; or


* four medium-weighted activities



Additional updates include


* reduced barriers to patient-centered medical home designation by removing specific examples of entity names of accreditation organizations or comparable specialty practice programs;


* increased participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice needing to perform the same Improvement Activity; requiring that a group must perform the same activity during any continuous 90-day period within the same performance year; and


* provision of a new Improvement Activity for participation in a coronavirus disease 2019 (COVID-19) clinical trial.2


* Provision of a new Improvement Activity "Use of telehealth services that expand practice access." The activity description states, "Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients." Check it out to see if you meet the requirements for reporting this medium-weighted activity.



The Promoting Interoperability performance category focuses on the electronic exchange of health information to improve patient access to their health information, exchange of information between providers and pharmacies, and systematic collection, analysis, and interpretation of healthcare data. This performance category is weighted at 25% (no change from PY 2019). You must submit collected data for certain measures from each of the four objectives measures (unless an exclusion is claimed) for the same 90 continuous days (or more) during 2020. The last 90-day performance period begins on October 3, 2020. Additional updates are as follows:


* inclusion of the Query of Prescription Drug Monitoring Program (PDMP) measure as an optional measure (available for bonus points);


* removal of the Verify Opioid Treatment Agreement measure;


* answer of "yes" for the Prevention of Information Blocking Attestation, the ONC Direct Review Attestation, and the Security Risk Analysis measure within the performance period calendar year; MIPS eligible clinicians must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary, and correcting identified security deficiencies;


* reduction of the threshold for a group to be considered hospital-based (instead of 100% of clinicians, more than 75% in a group must be hospital-based individual MIPS-eligible clinicians for the group to be excluded from reporting the measures under the Promoting Interoperability performance category and to have this category reweighted to zero);


* requirement of a "yes/no" response instead of a numerator and denominator for the optional Query of PDMP measure as started in PY 2019; and


* redistribution of the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Electronic Access to Their Health Information measure (if an exclusion is claimed) as started in PY 2019.



CMS provides an opportunity for qualifying clinicians and groups to apply for exceptions to meeting the MIPS program requirements. In certain circumstances, these exceptions may be applied automatically:


* Extreme and Uncontrollable Circumstances Exception Application. This application allows you to request reweighting for any or all performance categories if you encounter an extreme and uncontrollable circumstance or public health emergency, such as COVID-19, that is outside of your control. You can sign up for this exception through December 31, 2020, 8 PM ET. New for 2020, you need to sign into with your HCQIS Access and Roles Profile account and select "Exceptions Applications" on the left-hand navigation, then "Extreme and Uncontrollable Circumstances Exception," and complete the application.


* Promoting Interoperability Performance Category Hardship Exception Application. This application allows you to request reweighting specifically for the Promoting Interoperability performance category.


* You can submit an application to have your MIPS Quality, Cost, Improvement Activities, and/or Promoting Interoperability performance categories reweighted to 0% because of COVID-19 if you meet certain criteria.



Remember, it is important to retain documentation of your circumstances supporting your attestations in the event you are selected by CMS for DVA. CMS has put this program in place to ensure program integrity, data accuracy, and compliance for the MIPS. Merit-based Incentive Payment System-eligible clinicians, groups, and virtual groups are required to provide substantive, primary source documents as requested by CMS if requested for a DVA. Good luck!




1. The Quality Payment Program. 2020. Last accessed July 20, 2020. [Context Link]


2. Dear Clinician. 2020. Last accessed July 20, 2020. [Context Link]