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AVOIDING A NEGATIVE PAYMENTChoose 1 High-Weighted Activity to avoid the penalty in 2018 and receive the full 15 points (select one from below).

Improvement Activity* Notes

24/7 Access24/7 access to clinicians who have real-time access to the medical record. Provide access to the care team for advice about urgent care, such as during evenings or on weekends.

Consultation of the Prescription Drug Monitoring program

Clinicians would attest that, 60 percent for the transition year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days.

Seeing new and follow-up Medicaid patients in a timely manner including patients dually eligible

1) Timely Appointments for Medicaid and Dually Eligible Medicaid/Medicare Patients - Statistics from certified EHR or scheduling system (may be manual) on time from request for appointment to first appointment offered or appointment made by type of visit for Medicaid and dual eligible patients; and 2) Appointment Improvement Activities - Assessment of new and follow-up visit appointment statistics to identify and implement improvement activities.

Patient-Centered Medical Home (PCMH)

Practice who are PCMH recognized gets full credit, no need to do anything else (15% is good).

Preparing for MIPS 2018SMALL PRACTICES – 1-15 PROVIDERS

SMALL TO MODERATE PAYMENT ADJUSTMENTTo get to the 40+ points to see a small to moderate payment adjustment, choose one High-Weighted Activity (see above), and Choose 6 Quality measures to work on via claims or EMR.

Quality Measure* DefinitionTobacco Use (226)

Percentage of patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling if identified as a tobacco user.

DM Poor Control (A1c>9%) (1)Percent of patients 18-75 years of age with diabetes whose most recent A1c is >9.0% during the measurement period, if NO A1c during measurement period numerator will still be counted.

BMI (128)Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

Fall Risk (154) Percent of patients 65 years and older who were screened for a future fall risk during the measurement period.

Pneumonia Vaccination (111) Percent of patients 65 years and older who have ever received a pneumococcal vaccine.

Influenza Immunization (110)Percent of patients aged 6 months and older seen for a visit between October 1, 2017 and March 31, 2018 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

✓

✓

*See more Improvement Activities examples: https://qpp.cms.gov/mips/improvement-activities

*See more Quality Measure examples: https://qpp.cms.gov/mips/quality-measures

MODERATE PAYMENT ADJUSTMENTTo get to the 70+ points to see a moderate payment adjustment plus hit the bonus mark, choose one High-Weighted Activity, Choose 6 Quality measures to work on via claims or EMR, and submit your Promoting Interoperability (formerly Advance Care Information) Measures.

Promoting Interoperability Definition

e-PrescribingAt least 100 permissible prescription written by the eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT (Certified Electronic Health Record Technology).

Security Risk Analysis Conduct or review a security risk addressing the security of PHI data created or maintained by CEHRT.

Provider Patient Access

The patient is provided timely access to view online, download, and transmit to health information to view online, download, and transmit to a 3rd party and to access using an application of their choice that is configured to meet specs of the API (Application Programming Interface).

Send Summary of Care (HIE)

For at least one transition of care or referral, the eligible clinician that transitions or refers their patient to another setting care of care or health care clinician -- (1) creates a summary of care record using CEHRT, and (2) electronically exchanges the summary of care record.

Request/Accept Summary of Care (2015 CEHRT)

For at least one transition of care or patient encounter in which the eligible clinician has never before encountered the patient, the clinician receives or retrieves and incorporates into the patients records an electronic summary of care document.

✓You must have these Base Measures completed for Promoting Interoperability in order to participate!

Do you need help with your participation in the QPP? Call us at 877.273.0129 to receive no-cost technical assistance

from one of our QPP experts.

www.neqpp.orgThis material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. QPPSURS18CENT2018051437

• DO NOT use ‘@’ in your usernameCreate ID

• Password must be seven characters and include a capital letter, number, and special symbol – cannot spell dictionary word (ex. Hock@y22)

Create Password

• Answer the three questions and save them for reference

• Close out and log back in

Challenge Questions

• Choose:

• PV: Physician Quality and Value Program

Request Application

• Provider ApproverChoose Group

Creating Your EIDM Account:Small Practices

Do you already have an EIDM account? If unsure, contact CMS at 866.288.8292

Go to http://portal.cms.gov

Click on “New User Registration”

Choose “PV: Physician Quality and Value Programs”

Agree to terms and conditions

Enter information only where necessary (skip where it says “Optional”)

*You will need your doctors individual PTAN and NPI # before you begin*

Please reach out to us for guidance: 877.273.0129

*Your Individual Medicare ID # (PTAN) can be found here: https://nppes.cms.hhs.gov/NPPES/Welcome.do

Select “Next” to complete the Identification Verification

Select “Agree” for terms and conditions then select “Next”

Prepare for Authentication Process by filling out email field (again) and add

your SSN#

Answer all Credit History Questions

Register your phone, computer, or email from the MFA Device drop down

menu

Request New Application Access will appear

Enter your business contact information

Role Type – Choose: “Create an Organization”

When creating this you will need to enter your practices credentials

A solo provider would enter their own NPI and PTAN

A group would enter the group TIN and the individual NPI &

PTANS of two of their providers

Reason for request = ‘MIPS’

Click on “Submit”

Select a Role:

If you are an INDIVIDUAL clinician use:Choose – “Individual Practitioner”

If you are a 2+ CLINICIAN practice use:Choose – “Security Official”

Error MessageIf you receive an Error Message saying PTAN, NPI or TIN is incorrect, hit the

Submit button again and the message will appear again. You will need to

do this three or four times until it passes to a manual audit process on

CMS’s side. It will then take a few days for them to approve and email you

back. You can also call CMS at 866.288.8912 for more assistance.

www.neqpp.org @NEQPPSupportCenter @NewEnglandQI

Do you need help with your participation in the QPP? Call us at 877.273.0129 to receive no-cost technical assistance

from one of our QPP experts.

* High Priority Only Medicare Part B patients are included in claims based reporting.

Specialty Specific Quality Measures to Avoid 2020 Penalty Here is a list to help you find six quality measures based upon your submission method.

One measure must be a high priority (*).

Quality Measure Definition Submission

Method

#1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)*

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

Claims

EHR QCDR

Registry

#226 Tobacco Use Percentage of patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling if identified as a tobacco user.

Claims

EHR QCDR

Registry

#128 BMI

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

Claims

EHR QCDR

Registry

#134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.

Claims

EHR QCDR

Registry

#130 Documentation of Current Medications in the Medical Record*

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

Claims

EHR QCDR

Registry

#238 Use of High-Risk Medications in the Elderly*

Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted:

1) Percentage of patients who were ordered at least one high-risk medication

2) Percentage of patients who were ordered at least two of the same high-risk medication

EHR QCDR

Registry

#47 Care Plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Claims

QCDR Registry

Internal Medicine PREPARING FOR MIPS 2018

* High Priority Only Medicare Part B patients are included in claims based reporting.

Common Core Quality Measures to Avoid 2020 Penalty

If you are having difficulty finding six total measures due to your specialty or submission method, here are a few more measures that may help you achieve the total.

Quality Measure Definition Submission

Method

#318 Falls: Screening for Future Fall Risk

Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

EHR QCDR

Registry

#236 Controlling High Blood Pressure*

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

Claims

EHR QCDR

Registry

#111 Pneumococcal Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Claims

EHR QCDR

Registry

#112 Breast Cancer Screening

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

Claims

EHR QCDR

Registry

#113 Colorectal Cancer Screening

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.

Claims

EHR QCDR

Registry

#110 Preventive Care and Screening: Influenza Immunization

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

EHR QCDR

Registry

Internal Medicine PREPARING FOR MIPS 2018