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How to submit a MIPS quality measure if you are not participating in an approved registry
UNDER THE MACRASCOPE How to submit a MIPS quality measure if you are not participating in an approved registry William P. Robinson, MD,a Brad Johnson, MD,b Jill Rathbun, MHSA,c and Karen Woo, MD, MS,d Charlottesville, Va; Tampa, Fla; Chicago, Ill; and Los Angeles, Calif
The “Test Pace” option of the Quality Payment Program (QPP) allows providers to submit a minimum amount of data to avoid the four percent payment penalty in 2019.1 Providers who choose to participate in test pace must do so starting no later than October 2, 2017 and submit data for a continuous 90-day period on all patients for which the selected measure(s) applies. To start, providers will check their 2017 QPP participation status by visiting www.qpp.cms.gov and inputting their national provider identifier (NPI) number on the home page. It is possible that your QPP participation requirements are covered by a program at your institution or at one of the institutions/hospitals where you see patients. Providers whose status requires them to submit data can participate in a registry which submits the data for them. Providers who are not participating in a registry will choose to submit one quality measure, one clinical practice improvement activity (CPIA) OR the core advancing care information (ACI) measures. Providers not participating in a registry must use quality or CPIA measures that are reportable by claims. The ACI measures can be submitted through a certified electronic health record. Providers who choose to submit one quality measure can go to: https://qpp.cms.gov/measures/ quality and search for a claims-based quality measure(s). Two suggested search parameters that will identify claims-based measures relevant to vascular surgeons: 1) Search via existing filters: High Priority Measure - Yes, Data Submission Method - Claims (NOT administrative claims), Specialty Measure Set - Vascular Surgery. This will identify three measures: (i) Care Plan;
From the Department of Surgery, Division of Vascular Surgery, University of Virginia, Charlottesvillea; the Department of Surgery, Division of Vascular b
Surgery, University of South Florida, Tampa ; the Society for Vascular Surgery Quality
and
Performance
Measures
Committee,
Chicagoc;
and
the
Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles.d Author conflict of interest: none. Correspondence: Karen Woo, MD, MS, 200 UCLA Medical Plaza, Ste 526, Los Angeles, CA 90095 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg: Venous and Lym Dis 2017;5:766 2213-333X Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvsv.2017.06.012
766
(ii) Controlling High Blood Pressure; (iii) Documentation of Current Medications in the Medical Record. 2) Search via keyword: keyword- vascular, Data Submission Method - Claims. (Do not select anything for the “High Priority Measure” and “Specialty Measure Set” filters.) Six additional measures will be identified: (i) Ischemic Vascular Disease: Use of Aspirin or Another Antiplatelet; (ii) Perioperative Anti-Platelet Therapy for Patients Undergoing Carotid Endarterectomy; (iii) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan; (iv) Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented; (v) Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention; (vi) Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure. The data for the selected quality measure(s) will be submitted on the same forms that you use to bill Medicare for services provided to patients. The measure specification includes: (1) codes used to identify the intended patient population, and (2) the codes you will input on the billing form to indicate whether the measure goal was achieved for a given patient. Measure specifications can be found at: https://qpp.cms.gov/resources/education, in the folder entitled “Quality Measure Specifications.” Download the folder and locate your selected measure(s) by its Quality ID number. When selecting measures to report, consider the clinical conditions you treat and what the burden may be to your practice staff to find these patient’s charts to submit the measures. You will need to review your current billing codes against the denominator of the measure to see which patients you need to report on for the measure.
REFERENCE 1. Ferrante G, Woo K, Rathbun J, Johnson B. Avoid the 4% penalty: pace yourself into MIPS by October 2, 2017. J Vasc Surg 2017;66:671.
The “Test Pace” option of the Quality Payment Program (QPP) allows providers to submit a minimum amount of data to avoid the four percent payment penalty in 2019.1 Providers who choose to participate in test pace must do so starting no later than October 2, 2017 and submit data for a continuous 90-day period on all patients for which the selected measure(s) applies. To start, providers will check their 2017 QPP participation status by visiting www.qpp.cms.gov and inputting their national provider identifier (NPI) number on the home page. It is possible that your QPP participation requirements are covered by a program at your institution or at one of the institutions/hospitals where you see patients. Providers whose status requires them to submit data can participate in a registry which submits the data for them. Providers who are not participating in a registry will choose to submit one quality measure, one clinical practice improvement activity (CPIA) OR the core advancing care information (ACI) measures. Providers not participating in a registry must use quality or CPIA measures that are reportable by claims. The ACI measures can be submitted through a certified electronic health record. Providers who choose to submit one quality measure can go to: https://qpp.cms.gov/measures/ quality and search for a claims-based quality measure(s). Two suggested search parameters that will identify claims-based measures relevant to vascular surgeons: 1) Search via existing filters: High Priority Measure - Yes, Data Submission Method - Claims (NOT administrative claims), Specialty Measure Set - Vascular Surgery. This will identify three measures: (i) Care Plan;
From the Department of Surgery, Division of Vascular Surgery, University of Virginia, Charlottesvillea; the Department of Surgery, Division of Vascular b
Surgery, University of South Florida, Tampa ; the Society for Vascular Surgery Quality
and
Performance
Measures
Committee,
Chicagoc;
and
the
Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles.d Author conflict of interest: none. Correspondence: Karen Woo, MD, MS, 200 UCLA Medical Plaza, Ste 526, Los Angeles, CA 90095 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg: Venous and Lym Dis 2017;5:766 2213-333X Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvsv.2017.06.012
766
(ii) Controlling High Blood Pressure; (iii) Documentation of Current Medications in the Medical Record. 2) Search via keyword: keyword- vascular, Data Submission Method - Claims. (Do not select anything for the “High Priority Measure” and “Specialty Measure Set” filters.) Six additional measures will be identified: (i) Ischemic Vascular Disease: Use of Aspirin or Another Antiplatelet; (ii) Perioperative Anti-Platelet Therapy for Patients Undergoing Carotid Endarterectomy; (iii) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan; (iv) Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented; (v) Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention; (vi) Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure. The data for the selected quality measure(s) will be submitted on the same forms that you use to bill Medicare for services provided to patients. The measure specification includes: (1) codes used to identify the intended patient population, and (2) the codes you will input on the billing form to indicate whether the measure goal was achieved for a given patient. Measure specifications can be found at: https://qpp.cms.gov/resources/education, in the folder entitled “Quality Measure Specifications.” Download the folder and locate your selected measure(s) by its Quality ID number. When selecting measures to report, consider the clinical conditions you treat and what the burden may be to your practice staff to find these patient’s charts to submit the measures. You will need to review your current billing codes against the denominator of the measure to see which patients you need to report on for the measure.
REFERENCE 1. Ferrante G, Woo K, Rathbun J, Johnson B. Avoid the 4% penalty: pace yourself into MIPS by October 2, 2017. J Vasc Surg 2017;66:671.