MIPS Open ForumQuality Performance CategoryAugust 24, 2017

Shannon Fogh, MD – University of California San Francisco

Terri Henning & Susan Ingram -Toledo Radiation Oncology, Inc.

K.D. Lanning - Southeast Radiation Oncology

Angela Kennedy -ASTRO

Ksenija Kapetanovic - ASTRO

Randi Kudner - ASTRO

Welcome

• MIPS Reminder• Quality Performance Category

• Overview• Submission mechanisms• Strategies from the field

• Q&A

Merit-based Incentive Payment System (MIPS)

Quality 60%

ACI 25%

IA 15%

• Eligibility• Bill >$30K Medicare Part B AND

• See >100 Medicare patients AND

• Not the first year of Medicare Part B

• Submission Mechanisms• Qualified Clinical Data Registry (QCDR)

• EHR

• Registry

• Claims

• CMS Web Portal

Merit-based Incentive Payment System (MIPS)

Quality Performance Category

Quality Performance Category

Each Quality Measure (3-10 points)

• 3 points = submit any data• >3 points = meet data

completeness• 50% of applicable

patients – all payers• 20 patients• 90 consecutive days• Benchmark exists

Quality Reporting: Claims

• Dose Limits Measure (#156)

• CPT II Codes added to Claims

• 50% of applicable Medicare patients

• Claims is only available for individuals, not group reporting

Quality Reporting: QCDR

Quality Reporting: QCDR

Quality Reporting: QCDR

Quality Reporting: QCDR

Shannon Fogh, M.D.

Assistant ProfessorQuality Assurance DirectorDepartment of Radiation Oncology

Combines legacy programs into single, improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

What is the Merit-based Incentive

Payment System

14

Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, you will record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can provide care during the year through that model.

Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. In order to earn the 5% incentive payment for participating in an Advanced APM, just send quality data through your Advanced APM.

Feedback: Medicare gives you feedback about your performance after you send your data.

Payment: You may earn a positive MIPS payment adjustment beginning January 1, 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you could earn 5% incentive payment in 2019.

2017Performance Year

March 31, 2018Data Submission

Feedback January 1, 2019Payment Adjustment

Feedback available adjustmentsubmitPerformance year

When Does the Merit-based Incentive

Payment System Officially Begin

• Submit minimum amount of 2017 data to Medicare

• Avoid a downward adjustment

20

1 Quality

Measure

1 Improvement

Activity

4 or 5 RequiredAdvancing

Care Information Measures

OR OR

You Have Asked: “What is a minimum amount of data?”

MIPS: Choosing to Test for 2017

1 Quality

Measure

1 Improvement

Activity

• Attest to participation in activities that improve clinical practice

▪ Examples: Shared decision making, patient safety, coordinating care, increasing access

• Clinicians choose from 90+ activities under 9 subcategories:

4. Beneficiary Engagement

2. Population Management

5. Patient Safety and Practice Assessment

1. Expanded Practice Access 3. Care Coordination

6. Participation in an APM

7. Achieving Health Equity8. Integrating Behavioral

and Mental Health9. Emergency Preparedness

and Response

MIPS Performance Category:

Improvement Activities

https://qpp.cms.gov

Smoking Cessation Project

Smoking Cessation Project• Calculate the number of patients who had ANY of these CPT codes: 99201, 99202, 99203,

99204, 99205 (new patient visits) during December 2014, January 2015, and February 2015 in the Radiation Oncology department at UCSF (any location).

• Within this set of patients, fine the number of patients who use tobacco as indicated in Apex

• In the History section, Tobacco Use subsection, Smoking status - ANY of these: "current everyday smoker", "current some day smoker", "heavy tobacco smoker," "light tobacco smoker", or "smoker- current status unknown").

• Within this subset of patients who use tobacco, we use 3 separatesearches (just for numbers of patients, no patient identification) for three different selectable choices in the Apex tobacco use page:

• Search 1: “Counseling given.”

• Search 2: “Ready to Quit”

• Search 3: “Marked as Reviewed”

Technical Assistance

• Free, hands-on training and support for practies of 15 or fewer clinicians: https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf

• Resource Library: https://qpp.cms.gov/about/resource-library

• CMS Service Center: 1-866-288-8292• Email support: QPP@cms.hhs.gov

Terri Henning & Susan Ingram

Chief Operating Officer & Coder

Pathway to MIPS

I. Understanding and Implementing MIPS at Toledo Radiation Oncology

A. Teamwork

i. Physicians

Monthly meetings, training sessions, and handouts

ii. Administration

Organize program outline, training sessions, and program buy in

iii. Coder

Educate staff, data tracking, and input data into Wizard

iv. Billing and Auditing Department

Review documentation to ensure necessary data is documented

B. Group-Registry-partial year - OH practice

Individually-Claims-test pace - MI practice

C. Currently reporting for 12 physicians and 1 NP

i. NP will report Group Registry - OH

Toledo Radiation Oncology 25

Pathway to MIPS cont.

II. Participation Programs

A. 2007 PQRI reporting via claims (2011 changes to PQRS)

B. 2010 eRx

C. 2011 Meaningful Use/EHRi. Issue of ownership of electronic health recordii. Hardship exemptions offered

D. 2013 PQRS registry reporting starts using ASTRO Wizard

E. 2017 MIPS Wizard

F. Goal of partial participation for 2017 is to prepare for increased reporting requirements in 2018

Toledo Radiation Oncology 26

Pathway to MIPS cont.

III. Evaluation

A. Time

i. Physicians- education and incorporate changes into current practice patterns

ii. Evaluate each department staff/productivity levels/ skill set to implement the new Quality = program without hiring additional staff

B. Training

i. Monthly discussion with handouts containing updated information for Physicians,

= administration, and staff that need trained on the different aspect of MIPS.ii. Keep up to date so informed decisions can be made

C. Costs

i. IT to ensure compatible EHR

ii. Assess the cost of training staff and materialsiii. Implementing the Quality program to fulfill the requirement and to make 2017 a beta

= learning year in order to prepare for 2018

Toledo Radiation Oncology 27

Determining MIPS PathGroup vs Individual

Group reporting data is collected by the Tax Identification Number (TIN).• Groups are not able to report using claims. Groups can report via registry or EHR.• Decision- make 2017 MIPS a learning year for preparation for future years

• Groups report on 50% of ALL payer claims.• Increases data collection

• All providers in the group must report on the same measures.• Entire group reporting on the same measures - keeps process/changes universal

• Advancing Care would be able to be met by one or more physicians utilizing the CERHT. One numerator and denominator must be submitted for each measure.

• Ownership of data (concern) - allows group reporting from single EHR

Toledo Radiation Oncology 28

Determining MIPS PathGroup vs Individual

Individual reporting data is collected by the National Provider Number (NPI).• Individual Physician reports using claims, registry, or EHR. • Determined that while this allowed more flexibility, lesser cost (by reporting test pace) - lack of group

consistency

• Individuals report on 50% of Medicare claims.• Less data collection

• Individual reporters can pick their own measures.• Allows physician to report on measures of choice - creates multiple consistency issues

• Individuals would have to apply to have the Advancing Care category reweighted to the Quality category if CEHRT is not available.

• EHR ownership - Hardship Exemption - reweight ACI (unless report test pace)

Toledo Radiation Oncology 29

K.D. Lanning, RN, MSN

Manager, Value Based Payments

34- Radiation Oncologists

5- Mid-levels (NP and PA)

18- hospital based facilities

(8- healthcare systems/independent hospitals)

2- free standing centers

3- separate TINs

(Hospital Based TIN, 2-FSC TINs)

Reporting SERO as a group (single TIN) with aggregated data for 90 days

Reporting ROCC (FSC) as a group for full year, own the HER. Less volume of data

• We choose to use MIPS Wizard to report Quality data only because I am familiar with their file upload format

• Due to the fact that we are doing full year reporting for our FSC I needed to be able to start to collect data on Jan. 1, 2017.

• I built spreadsheets with the column headers from MIPS Wizard to keep track of the data

• Will use the attestation submission method for ACI and IA that will be free on qpp.gov

MIPS Wizard data upload featurePatient Tab

Encounter Tab

Quality Performance Category

Upcoming ASTRO MIPS Events

Quality Payment Program Session

Date: Monday, September 25th

Time: 10:45 a.m. – 12:15 p.m. Place: Convention Center – Room 6 D/E

CME: 1.50 AMA PRA Category 1 Credits™

Upcoming ASTRO MIPS Events

MIPS Office Hours

Hours of Operation – Conference Center, Room 9Sunday, September 24 2:30 - 4:00 p.m.

Monday, September 25 10:00 – 11:00 a.m.2:30 – 3:30 p.m.

Tuesday, September 26 10:30 – 11:30 a.m.2:00 – 3:00 p.m.

We Are Here to Help

WWW.ASTRO.org/MIPS MIPS@ASTRO.org MIPS Toolkits