What You Should Know About Clinical Practice Improvement Activities And MIPS In 2017

There are three groups of clinicians that will not be required to participate in the Merit-Based Incentive Payment System (MIPS):

• clinicians who are in their first year of participating in Medicare Part B;
• clinicians who have Medicare billing charges less than or equal to $10,000, and/or provide care for 100 or fewer Medicare patients in one year;
• those who are participating in advanced Alternative Payment Models (APM). Check your status with the APM program that you may be participating in. (Some people may be already in Accountable Care Organization and these ACOs may be designated as APMs.)

If you are in any of the above categories, you can stop reading now. Otherwise, the rest of us will need to consider further what the program requirements will be for us starting on January 1, 2017.

Currently, there are multiple quality and value reporting programs that you may already be engaged in as a Medicare provider. These programs include the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM) program, and the Meaningful Use Electronic Health Records (MU-EHR) Incentive Program. 

The MIPS combines the currently independent programs into one to ease our burden. However, MIPS has added a new, never seen before fourth performance category to promote ongoing improvement and innovation to clinical activities on care coordination, beneficiary engagement and patient safety. This fourth program is Clinical Practice Improvement Activities (CPIA). Let us take a closer look at this program.

Based on the four categories of quality (60 percent), resource use (0 percent for 2017, 10 percent in 2018), clinical practice improvement activities (15 percent) and advancing care information (25 percent), a single MIPS composite performance score (CPS) will be calculated and assigned to you.

In the first year of the program in 2017, only three categories will go into calculating the MIPS composite score. Resource use (or cost) will not be included in the calculation during this first year and the weighting of this category has been set to zero. You may still want to monitor your cost data that the Centers for Medicare and Medicaid Services (CMS) will calculate from claims data. In future years, your cost score, or “resources used and cost to the system,” will help calculate your MIPS composite score valued at 10 percent, based on 40-plus cost measures to account for differences among specialties.

Maybe you are like me and can’t wait for your EHR vendor or practice administrator to tell you how you are going to achieve the required reporting and what the categories and measures consist of. I started to do research on my own and found that CMS has provided us with a great online tool. We can use this tool not only to learn about the Quality Payment Program but we can start to decipher the Quality Measures, Advancing Care Information Objectives and Measures and Improvement activities. I can drill it down to the specific measures that I want to report on. I can determine whether I should report a specific measure via claims reporting or registry reporting. I can assess if the CPIA is a medium weight or high value activity, and determine if that activity is achievable for my practice with the resources I already have.

This tool is available at the Quality Payment Program home page: https://qpp.cms.gov/ .

I have now downloaded a .csv file for each of the three categories and the measures within each category that I feel I can achieve in my practice. I will use this list to speak with my electronic medical record (EMR) vendor on how the program will allow me to collect the information I need when the time comes for reporting the data that would have been collected through the process of patient visits and documentation. I will ask my vendor where this information is documented in my charting (note template) and, if necessary, I can discuss how we can modify the note template to allow the collection of this information to be user-friendly for my staff, patients and myself so the workflow is not impacted. This method will allow me to see if there are gaps in my templates, with the EMR vendor or the EMR program itself as it perhaps may not have the capability of collecting this information in a reportable format.

I can use the same lists to speak to my practice management software vendor or billing service provider in regard to how I can report these measures. There are quality measures that we can report by claims and some that require reporting my registry. Depending on the measures I choose, I can report some measures by claims, if this will be easier, and others by registry.

What The CPIA Measures

Let’s take a deeper look into the new category: Clinical Practice Improvement Activities (CPIA). These activities will comprise 15 percent of your MIPS composite score. There are 92 activities for you to choose from. Items on the list include: implementation of fall screening and assessment program; engagement of patients through implementation of improvements in a patient portal; regularly assessing the patient experience of care through surveys or other methods; and tobacco use screening and cessation intervention.

Most providers will attest that they have completed up to four improvement activities for a minimum of 90 days. However, if you are in a group of 15 or fewer (this includes if you are solo practitioner), or if you are in a rural or health professional shortage area, you will attest that you have completed up to two activities for a minimum of 90 days to get the full credit for the measure.

If you happen to participate in a patient-centered medical home or an advanced payment model designated as a medical home model by CMS, you will automatically earn full credit for this category.

Since the 2017 participation year is less stringent, let me summarize the Clinical Practice Improvement Activities Performance Category.

You can report on a minimum of one CPIA activity for a partial score and you can obtain full scoring if you select at least one more activity if you are in a group of fewer than 15 providers. 

• First activity gets you 50 percent of the 60 points
• Second activity gets 100 percent of the 60 points

Activities denoted as “high” can earn 20 points each and those designated as “medium” can earn 10 points each.

Full credit is achieving 60 points. You get full credit if you participate in a patient-centered medical home or a comparable specialty practice. You can get half of the credit along for just participating in an Alternative Payment Model with opportunity for full credit by selecting additional activities.

A total of 15 percent of the MIPS composite score is attributed to the CPIA category.

There are potentially five ways to report the data for the CPIA performance category if you are reporting as an individual:

• Attestation
• Qualified clinical data registry (QCDR)
• Qualified registry
• EHR
• Administrative claims (if technically feasible with a specified modifier)

If you report as a group, you have all of the same reporting methods as the individual practitioner and the additional method to report by CMS web interface (for groups of 25 or more).

As you can see, for this activity to get the maximum credit of 60 points, you can select any combination of activities:

• High- and medium-weighted items
• All high–weighted items
• All medium-weighted activities

How the actual scoring process works is a simple division equation:

Total CPIA points ÷ total possible CPIA points (60) = CPIA performance category score

If I choose to complete one high-weight activity and earn 20 points, and then complete three medium-weight activities (earning 30 points), I will get 50 total points total:

50 total points ÷ 60 total possible points = 83% CPIA score

I would then earn 12.5 points toward my MIPS Composite Performance Score since my score would be multiplied by the weight for this category:

83% CPIA Score x 15% weight for CPIA = 12.5

The CMS says performance feedback will be available at least annually starting July 1, 2017 and clinicians or groups will be able to request a targeted review of the calculation of payment adjustments. The CMS has set the performance threshold minimum at three and the exceptional threshold at 70. At the threshold of three, which would only require you to report one quality measure, you would avoid the negative adjustment penalty. If you can get the exceptional level of 70, then you would be eligible for a bonus payment. Those in between the low and highest threshold are in the category of no financial impact being either bad or good.

Five Things You Can Do Now To Prepare For The Start Of MIPS

1. Immediately educate all those in your organization, including medical assistants, billing office personnel, doctors and management staff.
2. You can estimate your MIPS score using your current MU, PQRS and VBM scores.
3. Since MU and PQRS/VBM will comprise 85 percent of the 2017 MIPS score, optimize them now since you will still need to report them for 2016.
4. Evaluate staff, resources (this usually means money but it could mean your EMR) and your practice from an organizational perspective on how you will meet the MIPS program requirements.
5. Identify how 2017 will impact 2018 Alternative Payment Model and or MIPS participation. Are there Medicare Shared Savings Program Track 2/3, Accountable Care Organization or other Advanced Payment Model programs that you may want to participate in? What are their application deadlines or their requirements?

There are several MIPS calculators on the web that you can use to help you determine your level of participation or if you decide not to participate in the program, how that will impact you financially.