CMS Web Interface Kick-Off Webinar

December 11, 2019

All right. Hi, everybody and thank you for joining today's CMS Web Interface

kick Off. During this webinar CMS will provide an overview of 2019 CMS Web

Interface quality reporting for MIPS Groups and ACOs. After the webinar, CMS

will take as many questions as time allows. So, now, I'll turn it over to

Lisa Marie Gomez from CMS to begin.

Thank you and welcome everyone, and thank you for joining us today, as ACOs,

MIPS Groups, and Virtual Groups prepare to report quality data via the Web Interface. Again, my name is Lisa Marie Gomez and I'm with CMS. I'm a subject

matter expert regarding the Web Interface. Joining me on the call today are

other CMS subject matter experts and contractors who will share helpful

information regarding quality data reporting through the Web Interface. And we'll also answer any questions during the question and answer session after

today's presentation. Today's call is focused on quality reporting. You can

contact the Quality Payment Program Service Center with any other questions

regarding Promoting Interoperability, Improvement activities, MIPS or other

Quality reporting questions that you may have, that may not be covered in

today's presentation. Next slide please.

So, before we get -- begin this presentation, we just want to note that the

information presented in today's presentation is current at the time of its

publication. The Medicare policy changes frequently, so, we encourage you to

review and use the resource documents and links that are provided throughout

the presentation. And please stay tuned for any communication from the

Quality Payment Program, Medicare Shared Savings Program, or Next Generation

ACO model regarding any updated information. Next slide please.

So, today we want to go over just a few announcements. So, the resources

listed on this slide have been posted to the Quality Payment Program Resource

Library and Webinar Library. You can access the CMS Web Interface User Guide,

FAQs, Excel Template, Data Dictionary, Fact Sheet, and the CMS Web Interface

Demonstration webinar, the recording, the presentation slide, and the

transcript. Next slide please.

So, we just want to highlight a few key dates. So, the submission period for

the CMS Web Interface will align with other submission types for the 2019

Performance Year which opens on January 2nd, 2020 and it closes promptly at

8:00 pm Eastern Daylight Time on March 31st, 2020. Please note that there is

not a test period for the CMS Web Interface as the submission period is now

longer and spans a three-month timeframe, So, you will have a longer period

to submit your data as compared to previous years. So, once the submission

period closes, the CMS Web Interface will automatically accept your

submission. As a reminder, the CMS Web Interface is accessible using the

“Sign In” link on the Quality Payment Program website. Next slide please.

We want to highlight a new feature for program year 2019 which is

specifically the Other CMS Approved Reason skip requests which must be

submitted through the CMS Web Interface. So, once the submission period opens

on January 2nd, 2020, we encourage you to submit any skip requests that you

may have early in the submission period in order for us to ensure that we're

able to review and process all skip requests that are submitted. So, again we

want to make sure that you're able to submit those all in advance so we can

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process through all of the skip requests that are submitted and get them

completed before the submission period closes. As a reminder, the 2019 CMS

Web Interface Application Programing Interface, also known as the API, is

available all year for testing in the developer preview environment. For more

information you can -- it can be found using the link provided on this slide.

Next slide please.

So, now, we want to just go over upcoming support calls that we have starting

in January of 2019. So, all weekly support calls listed below will be held on

Wednesdays from 1:00 pm to 2:00 pm Eastern Standard Time. Our first call will

be held on Wednesday, January 15th, 2020, and the topics for that support

call will include PREV-10, reporting within the CMS Web Interface, Assignment

and Sampling FAQs, frequently asked measure questions covering the following

measures: DM-2, HTN-2 and PREV-7. Additional topics maybe added prior to the

support call. Next slide please.

So, this next section we will cover the CMS Web Interface reporting

requirements. Next slide please.

So, for the reporting requirements, all organizations, regardless of size,

are required to confirm, and complete an accurate report on a minimum of 248

consecutively ranked Medicare patients for each measure. If you skip a

patient, they will be replaced with the next consecutively ranked beneficiary

until a total of 248 are reached. If the pool of eligible sampled patients is

less than 248, then your organization is required to report on all sampled

patients. Complete reporting of all 10 CMS Web Interface quality measures

will meet requirements for the Quality performance category for the 2019

performance year. MIPS groups, virtual groups, and eligible clinicians

participating in an ACO must meet MIPS reporting requirements for all

performance categories to avoid the 2021 MIPS negative payment adjustment.

Next slide please.

ACOs that fail to report all measures will not meet the Quality performance

standard and will be ineligible to share in savings, if earned. For the

Shared Savings Program ACOs participating under two-sided risk tracks,

failure to meet the Quality performance standard will result in the ACO owing

the maximum in losses, if they owe losses. MIPS eligible clinicians who are

scored under the MIPS APM scoring standard and have reassigned billing rights

to the Shared Savings Program ACO participant TIN in a Shared Savings Program

ACO that fails to satisfactorily report the CMS Web Interface measures for

ACOs will get a MIPS Quality performance score of zero unless they report

separately for the ACO, either as a group or a solo practitioner TIN. So,

right now I'm going to turn the presentation over to Chris Reinartz. Chris?

Thanks Lisa Marie. Okay. So, I'm going to give a quick overview of how you

would gain access to log on to QPP and connect to the Web Interface

application. HARP is our Identity Management System. Next slide please.

So, as in years past, anyone needing access to the CMS Web application is

going to need a HARP user ID and password. So, to create a HARP account you

would log on to QPP and click “Sign in.” If at this point you already have a user ID and password, you would just be able to enter those and you'd have

access to the system. If you don't already have your HARP credentials, then

you're going to need to click on “Register.” Once you've done that you provide your legal name, your date of birth, your address, and your Social

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Security Number. And then you'd go through this one-time process to set up

your user ID and password. Part of the process is going to be an identity

proofing exercise where we'll lead you through a series of multiple-choice

questions where you'd provide some personal information or confirm some

personal information and this is a Federal security requirement applicable to

our Quality Payment Program. Next slide please.

So, once you have your username and password, you would also set up a multi-

factor authentication where you're just going to select whether or not you

want to receive a text or email or a phone call to give you a confirmation

code that you would use each time you log into the system. And again, that's

just a one-time process. So, this should give you the ability to log on to

QPP and from there you have to set up any of the organizations which you were

needing to access the Web Interface for, whether that be a ACO or a group

practice or virtual group.

So, this would take you to a pretty simple workflow. Once you get into QPP,

you click on the “Connect to an Organization” link in the Manage User tab or Manage Access tab, and that's going to take you to the workflow that would

lead you to selecting your organization's name against our database, and then

you would select the type of role you would need. And basically we have two

separate roles, you're either going to enroll as a Security Official or

you're going to enroll as a staff user. So, if you're the first one setting

up the organization you -- you're mandated to become a security official. The

difference between the two roles is the staff user has “Read and Submit Data

Access.” The Security Official has both “Read and Submit Data Access” as well as an additional functionality where they can approve subsequent user

requests. You can have multiple Security Officials for your organization,

that's up to you how you want to handle that.

All of this is handled or laid out in a lot more detail than what I've

provided here and you can find that on our Resource Library, on our QPP site

and specifically you're looking for the Quality Payment Program Access User

Guide. And if you have any problems during the setup of your user credentials

you can contact our service center at the telephone number listed on this

slide or the web address listed on this slide. That concludes my portion of

the demonstration. I'm going to turn this over to Ozlem and she's going to

provide a little more background on some of the system functionality.

Okay. Good afternoon everyone. I'm Ozlem Tasel. I would like to show you the

steps you will need to follow to enter the CMS Web Interface through QPP. The

orange arrows on these images are to direct your attention to the areas that

you'll need to click on or enter data. But to access the CMS Web Interface,

you're going to have to first sign in to QPP. You'll click on the Sign In on

the Quality Payment Program screen. Next slide please.

You will need to next -- need to -- you will need to enter your user ID and

password. Check the Statement of Truth checkbox to agree and then click the

Sign In button. Next slide.

QPP requires two-factor authentication to sign in. A verification code will

be sent to your selected method of two-factor authentication. You will have

to enter that code here, then click the Verify button. Next slide.

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After signing into QPP, you can either click the Eligibility and Reporting

link on the left navigation menu or click the Start Reporting button on the

page. Next slide.

The following steps to navigate to the CMS Web Interface is slightly

different for ACOs, groups, and virtual groups. First, I'll show you the

navigation for ACOs. If you're an ACO, when you reach the Eligibility and

Reporting page, you will see a page that looks like this. Above the

Eligibility and Reporting page title, Performance Year 2019 will be selected

by default. Under the APM Entities tab, there will be a list of APM entities

that your account is associated with. Next to each entity on the list, you

will have a Start Reporting button. Once you click on the Start Reporting

button, you will enter the CMS Web Interface for the selected APM entity or

ACO. Next slide.

And here, you see the landing page for the CMS Web Interface. On the left-

hand side, there's a navigation menu where you can click to navigate to View

Progress, Report Data, View Reports, Manage Clinics, Manage Providers, and

Frequently Asked Questions. On the right-hand side, there's a Milestone

Timeline that helps you understand where you are during the submission

period. Next slide.

If you're a MIPS group then you will have a few extra steps. Next slide.

On the Eligibility and Reporting page, select the Practices tab to see a list

of practices your account is associated with. Next to each practice name, you

will see the Report As Group button. Click on the Report As Group button.

Next slide.

You will be navigated to the Reporting Overview page. In the Quality section

of this page, click on the CMS Web Interface link to access the system. Next

slide.

And here you see the same CMS Web Interface landing page that we saw for

ACOs. It has the same left navigation, the same Milestone Timeline and the

same options on the page. Next slide.

Lastly, if you're a virtual group, you will need to take the following steps

to access the CMS Web Interface. Next slide.

Again, on the Eligibility and Reporting page, you would select the Virtual

Groups tab to see a list of virtual groups your account is associated with.

Next to the Virtual group name, you will see the Start Reporting button.

Click on the spot -- Start Reporting button. Next slide.

You will be navigated to the Reporting Overview page. In the Quality section

of this page, click on the CMS Web Interface link to access the CMS Web

Interface application. Next slide.

And here you see the same CMS Web Interface landing page again that we saw

for ACOs and Groups. Again, the same left-hand navigation, the same Milestone

Timeline, and the same options available on the page. Next slide.

CMS Web Interface Submission Methods. Next slide please.

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There are three ways you may submit data for CMS Web Interface reporting:

Manual Data Entry via the User Interface; MS Excel File Upload; and CMS Web

Interface API Application Programming Interface. These methods can be used in

any combination to complete your reporting. You can upload data using the

Excel File Uploads functionality and then in the User Interface, select the

update beneficiaries manually through the data entry pages. Similarly, you

can submit data via Web Interface API and then do an Excel File Upload or use

the Data Entry pages. The submission of data can be completed in any

combination of these methods. Next slide.

Other CMS Approved Reason Skip Request Process.

This year, Other CMS Approved skip requests can only be submitted manually

through the CMS Web Interface. Now, I'd like to show you the steps you'll

need to follow to submit a skip request. Next slide. Oh, actually, if you can

stay on this slide please. Once you identify a patient to request a skip for

Other CMS Approved Reason, you will first need to confirm the patient for

sample by selecting Yes for, “Can you locate the patient's medical records

and is this patient qualified for the sample” question. Once you've selected Yes… next slide please.

You will scroll down to the appropriate measure and under, “Is the patient

qualified for this measure?” question, click on the No - Request Other CMS

Approved Reason link. Next Slide.

Clicking on that link will bring up the skip request model. In this model,

submitter information as well as the measure name and patient rank will be

automatically filled in for you. In order to complete your request, you will

need to enter your e-mail address and a description of why the patient is not

qualified for this measure. Once all the required information is entered, you

can click Request CMS Approval button to submit your request. Next slide.

Upon submitting the request, skip request confirmation dialogue will appear.

Click on Dismiss link to close the confirmation dialogue. Next slide.

Here you see that the patient is in incomplete status and a skip request was

submitted. You can click on View Case Details link to pull up the details on

this request. Next slide.

In addition to the details submitted for the request, you can click on “Show

Case History” link to see further details on this request. While the case is in review, the patient will stay in incomplete status. If the request is

approved, the patient will be automatically marked as Skipped and Completed.

If the request is denied, the case status will be marked as Denied and the

patient will stay in incomplete status. The patient will need to be completed

in order to complete your submission for this measure. Next slide.

Now I'm going to pass it off to Kara.

Thank you and good afternoon. This is Kara Sokol, and I will provide an

overview of assignment and sampling. Next slide.

The CMS Web Interface allows groups, virtual groups, and ACOs to report data

on a pre-determined population of patients. There are several steps completed

in order to determine this population of patients.

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First, beneficiaries are assigned to organizations based on current program

rule. For ACOs, CMS will use beneficiaries assigned using the ACO assignment

and alignment methodology. For groups and virtual groups, beneficiaries will

be assigned using the MIPS assignment methodology.

In the next step, assigned beneficiaries are assessed for their quality

reporting eligibility including measure specific denominator eligibility.

Beneficiaries who meet the following criteria will be excluded from quality

measurement eligibility. Beneficiaries with fewer than two eligible services

within the organization during the performance year will be excluded.

Beneficiaries with only part-year eligibility in Medicare Fee-For-Service

Part A and Part B will be excluded. Beneficiaries who are in hospice care,

who are deceased, or who did not reside in the United States will also be

excluded. For beneficiaries who are identified as eligible for quality

measurement, we determine if they are eligible for any of the specific

quality measures based on the denominator criteria as outlined in the 2019

CMS Web Interface Measures Specifications and supporting documents.

In the last step, eligible beneficiaries are randomly sampled into applicable

measures and loaded into the CMS Web Interface for quality reporting. Each

measure will have a sample size of 616 beneficiaries with the exception of

PREV-13, the statin therapy measure, which has a larger sample of 750. As

previously described, each organization is required to confirm and complete

data on 248 beneficiaries for each measure in order of rank with skip

beneficiaries replaced by the next in rank. If there are fewer than 248

eligible samples for a measure, the organization must report on 100% of those

included in the sample.

For more details on the sampling process including the visit codes used to

identify eligibility, please refer to the 2019 CMS Web Interface Sampling

Methodology document available online from the QPP Resource Library. We will

now move on to the measures overview. Next slide.

Hi. Angela Stevenson, can you please make sure your phone isn’t on mute?

Hi, this is Kayte from the PIMMS team. So, I will go ahead and speak through

these slides. So, what is showing on slide 42 is a list of the 2019 CMS Web

Interface Supporting Documents that are available on the Quality Payment

Program Resource Library. This includes the 2019 Measures List,. the

Narrative Measures Specifications and Performance Calculation Flows, the

Coding Documents, as well as the Release Notes that outline changes from 2018

to 2019. Next slide, please.

This slide shows the measures that were retired in 2019 including CARE-1, DM-

7, IVD-2, PREV-8, and PREV-9. Next slide, please.

This slide shows the list of 2019 Web Interface Measures available for

reporting during this submission period. And just to remind you that you must

submit data on all 10 Web Interface Measures for 2019. Next slide, please.

This slide outlines the 2019 Web Interface Measures with Substantive Changes.

These changes were covered in the Final Rule legislation. These measures

include MH-1 and PREV-10. We also have included Measures with Guidance

Clarification. These are updates that we have either received from CMS or the

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measure steward. And these measures include PREV-7 and PREV-12. Again, for

any – for full detailed listing of all changes to the 2019 Web Interface specifications, we would like to refer you to the 2019 CMS Web Interface

Release Notes. There are release notes for the narrative documents as well as

the coding documents. Next slide, please.

This slide outlines the Substantive Changes for MH-1. These changes include

an updated denominator, so the patient population now includes adolescent

patients from 12 to 17 years of age. It includes the PHQ-9M and the

Denominator Identification Period was updated from 11/01/2017 to 10/31/2018.

There's also updated numerator guidance expanding the measure assessment

period for 12 months plus or minus 60 days. And then additional denominator

exclusions were added. This includes patients with a diagnosis of

schizophrenia or psychotic disorder and patients with a pervasive

developmental disorder. Next slide, please.

This slide also outlines the denominator guidance that was updated. Just some

wording changes within the measure specification. And, additionally,

outlining that two rates will be reported, one for adolescent patients 12 to

17 years of age, and adult patients age 18 years and older. Next slide,

please.

This slide covers MH-1 frequently asked questions. Question one is, “Is the

PHQ-9M the same as the PHQ-9A for adolescents?” The answer is no. PHQ-9M is approved by the PHQ-9 developer and is contained within the Guidelines for

Adolescent Depression in Primary Care toolkit and the web link can be found

on the slide. The tool is found on page 63 of the toolkit. Question two: “Now

that the age range is 12 and-- 12 to 17 and 18 years and older, can we use

the PHQ-9 for all of our patients?” The answer is yes, you may use either of the PHQ-9 or PHQ-9M. Providers may elect to use either tool to meet the

intent of MH-1. Next slide, please.

This slide update-- excuse me, provides updates and substantive changes to

PREV-10. So, included here is-- excuse me, additional denominator guidance,

additional numerator guidance stating that cessation can be performed by

another healthcare provider, and the screening and cessation intervention do

not need to be performed by the same provider or clinician. The most recent

update is per the 2020 Final Rule. The requirement stating to use the

cessation intervention must occur during or after the most recent tobacco

user status is documented was removed. So, this update clarifies that

screening for tobacco use and cessation intervention do not have to occur on

the same encounter, both must occur during the 24-month look-back period.

Next slide, please.

This slide will cover some PREV-10 frequently asked questions. Number one:

“Is PREV-10 pay-for-reporting for 2019?” So, due to the mid-year change to the measure specification, CMS is reclassifying the measure as "pay-for-

reporting" in the Medicare Shared Savings Program. And the measure will be

excluded from MIPS scoring-- excuse me, provided it met with the date

completeness requirement and the measure was reported through the CMS Web

Interface. Number two: “Do we need documentation that we screened for both

smoking and smokeless tobacco to meet the screening portion of the measure?” No. For the measure steward, you did not need to document the patient was

screened for both smoking and smokeless tobacco for 2019 reporting. Question

three: “Can we just state the status as smoker, non-smoker, former smoker, et

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cetera to pass the measure or must it read ‘Tobacco’ status?” The answer is yes. A documented status for any type of tobacco use, for example, non-

smoker, smoker, or uses smokeless tobacco, meets the screening component of

the numerator. Next slide, please.

This slide will cover PREV-7 updated guidance. So, these are changes to the

guidance within the measure specification not considered substantive. So, for

this measure, the numerator guidance was updated that influenza during the

flu season or report previous receipt may not be completed during a

telehealth-- may or may not be completed during a telehealth encounter. So,

this change just intends to clarify that a screening where patient reports

previous receipt of influenza can be completed during a telehealth encounter.

Next slide, please.

Additional guidance updates include PREV-12. So, the initial population was

updated to all patients 12 years and older at the beginning of the

measurement period. Definitions were also updated for the tools listed on the

slide. Next slide, please.

Additional guidance updates include added examples of a Follow-Up Plan such

additional evaluation or assessment, completion of a Suicide Risk Assessment,

referral to a practitioner or program for further evaluation for depression,

and other interventions designed to treat depression such as psychotherapy,

pharmacological interventions, or additional treatment options. Next slide.

Here, we have a few PREV-12 frequently asked questions. Number one: “Does a

PHQ-2 or PHQ-9 score of a zero count if there's no documentation of the

results?” The answer is no. Per page 10 of the measure specifications, the results must be reviewed and verified and documented by the eligible

professional in the medical record on the date of the encounter to meet the

screening portion of the measure.

Number two: “If a patient answered ‘no’ to both PHQ-2 Q-- PHQ-2 questions but

there is no documented score, is this acceptable as documentation of a

negative screen?” No. Per page 10 of the measure specifications, the results must be reviewed and documented by the eligible professional in the medical

record on the date of the eligible encounter to meet the screening portion of

the measure.

And number three: “If the PHQ-9 or PHQ-2 questions are built in to the EMR

but are not labeled with the name of the screening tool, is this

documentation acceptable?” The answer is no. Per page six of the measure specification, the name of the age appropriate standardized depression

screening tool must be utilized and documented in the medical record. Next

slide, please.

This brings us to the end of our measures overview. I'll now hand things back

to Lisa Marie. Thank you.

Thanks, Kayte. So, the next few slides, we will continue to outline available

CMS Web Interface resources. Next slide, please.

The items currently listed on this slide are currently available on the

Quality Payment Program Resource Library. We'll continue to communicate any

future postings and upcoming Support Calls. The Help and Support page at

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qpp.cms.gov contain links to materials such as videos, webinars, and online

courses, as well as other items to help with reporting and development. Next

slide, please.

This slide contains links to resources available for the Medicare Shared

Savings Program ACO and for the Next Generation ACO Model. So, please check

those links or on other information for information linked to those programs.

Next slide, please.

If you need additional assistance, please refer to the contact information

listed on this slide. Again, contact help relates to the Quality Payment

Program, the Medicare Shared Savings Program for ACOs, and the Next

Generation ACO Model. Now, I'm going to turn the presentation over to Lauren

Keefer.

Great. Thank you. All right. Just a reminder you that if you'd like to help

us improve the Quality Payment Program, we are always looking for

participants to collaborate with us and provide feedback. So, please contact

the QPP Research Teams for any of our Human-Centered Design efforts. You can

do that by emailing QPPUserResearch@cms.hhs.gov. Okay.

And that brings up to the question and answer session of our webinar. Just as

a reminder, if you'd like to ask a question over the phone line, please raise

your hand using the hand icon in Go To and we will unmute your line. We will

go ahead and say your name just to let you know and then you can begin to ask

your question. Otherwise, you can always submit a question to the Questions

tab on your screen and we will read it out loud. We will address as many

questions as time allows but we do just want to go ahead and let everybody

know that during this webinar, we will not be taking questions on PREV-12.

So, if you have any questions concerning PREV-12, please contact the QPP

Service Center at qpp@cms.hhs.gov. Okay. So, the first question brings us to

-- let me just bring it up. Okay. First question is, “What are the deadlines

for Web Interface and when will data be available?”

Hi, this is Lisa Marie. So, the timeframe to submit any data for Quality via

the Web Interface is from January 2nd, 2020 to May 31st, 2020*1. And the

deadline is 8:00 PM. So once the submission period closes at 8:00 PM,

whatever data and information you have been submitted to the Web Interface,

that data will automatically be accepted and that’s the information that will

be assessed and scored. And then information in regards to how well you did

or like the report -- well, actually the reports for the Web Interface in

terms of -- on like the data that you submitted and reported, those reports

are actually available in the Web Interface. So, when you're navigating it,

as Ozlem showed you on the left-hand side, there's a navigation panel, and

then that's where you're able to see, like, the reports relative to the

information that you submitted via the Web Interface.

Just to clarify, this is Sarah from the Shared Savings Program. The Web

Interface reporting closes on March the 31st, not May the 31st.

Oh, sorry, did I say May? Sorry. I thought I said March. Sorry.

1 The deadline is March 31st, 2020.

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Great. Thank you. All right. Next question asks, “To get bonus points, can we

also submit electronic quality measures as well as the Web Interface?”

So, for bonus points relating to the Web Interface, so electronic upload of

your data using the API, using the Excel spreadsheet, those are ways in which

you're able to obtain bonus points. But if you report eCQMs, that's a

different means in terms of outside the Web Interface. But for the Web

Interface to obtain bonus points, it's, you know, doing the Excel upload,

it's, you know, using the API, using those means are ways to obtain bonus

points.

Okay. Great. Thank you. So, now we'll go to the phone line. We will go ahead

and see if Rhonda Johnson, we're going to go ahead and unmute your line, so

you may go ahead and ask your question.

All right. Moving back. Looking forward to next year’s Support Calls, can you

repeat the topics for the January 15th call please?

This is Lisa Marie. So, for the next support call on January 15th, 2020, the

topics that we will discuss will include PREV-10, reporting within the CMS

Web Interface, assigning and assembling FAQs, and frequently asked measure

questions covering the following measures: DM-2, HTN-2, and PREV-7. And there

may be other topics that we add prior to the support call but right now those

are the topics that we will be discussing on that call, on that support call.

Great. Thank you. All right. Your next question asks, they would like to get

clarification on PREV-10. “Can you please clarify that the cessation does not

have to be on or after the sedate -- sorry, tobacco user's data?”

A lot -- a lot of questions in the queue on this so I'll try to touch on

everybody's questions that are present within this slide deck. As Kayte

indicated back on slide 49 and she referenced the 2020 Final -- or QPP or

Quality Payment Program Final Rule, cessation no longer has to occur on or

after the most current screening for tobacco. You can go ahead and look

within the measurement year or the prior year to see if that cessation had

been provided to the patient. Thank you.

Okay. Great. Thanks. All right. We'll try the phone line again, so, Jason

Shropshire, you may go ahead and ask your question.

Hi, can you hear me?

Yup.

Hello?

Yeah.

Yeah. I want to clarify and make sure I got something correct because it's in

direct contradiction to what was told to us previously. So, the PREV-10

measure on the questions, since it's a measure question, it says you do not

have to ask smoking and smokeless. Well, previously, we were told you had to

do both. So, can you please clarify which is correct? Because that's a major

difference in the numerator.

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Yeah. You're so ahead of the curve. It's also in our queue. So, I'm going to

try to cover the gamut here and by all means folks on the line if you still

have clarifications or -- I'm not quite touching on the question you had,

please feel free to go back into that queue and submit another question. But

the measure truly is only for tobacco products, so any reference to e-

cigarettes or vaping or illicit drugs, marijuana, in such case that is --

that's not covered under this particular measure. It truly just looks at the

products and you don't have to do both.

Okay. But that's not answering my -- so you're saying is -- it's in our EHR,

it says like there's a tab for smoking and a tab for smokeless as long as

they just -- the provider just addresses the smoking tab only, that will meet

the numerator requirement.

You got it, Jason. That's correct.

Okay. Great. All right. Next question asks, ”For an ACO, is it submission on

248 patients for each measure to be the grand total for the entire ACO or is

it 248 patients for each measure for each 10 in the ACO?”

Hi, this is Ozlem. I'll try to answer this question. Once you log in to the

Web Interface for your ACO and start reporting, you will be required to

report on 248 patients for each measure for the ACO. So, your reporting would

be for the ACO, not for each individual TIN under your ACO. Thank you.

Great. Thank you, Ozlem. All right. Going back to the phone line, Yvonne

Barillas, we're going to unmute your line so you may go ahead with your

question.

Thank you. It was already answered.

Perfect. All right. Next question asks, “Would a diagnosis of dementia be an

exclusion for both the MH and Depression Screening Measures?”

Hi, this is Kayte from the PIMMS Team. So, for MH-1, no, dementia is not an

exclusion or exception for this particular measure. For PREV-12, dementia as

a standalone is not an exclusion, however, it could be considered if the

documentation is available that the patient was not screened due to their

diagnosis. Thank you.

Great. Thank you. All right. Next question is again on PREV-10. It asks,

“Within PREV-10, use of vaping and e-cigarettes is not a valid pass to

cessation. Does the use of the above vaping and e-cigarettes require a

cessation plan in place?”

So, since the -- thank you for the question. Since the PREV-10 only looks at

tobacco use, you -- and it doesn't look at e-cigarettes or vaping, you

wouldn't need a cessation plan for the measure in order to meet it, so no.

Okay. All right. Thank you. Back to the questions line, we have a question

from Linda Dodge. So, Linda Dodge, we have unmuted your line, you may go

ahead.

Can you hear me?

11

Yes, loud and clear.

Okay. In specific reference to chewing tobacco, that in our documentation is

not smokeless tobacco, does that count towards that measure? So, if you --

because we ask, "Do you smoke cigarettes? Do you chew tobacco?"

So, I'm looking at my team on this and we are trying to reach a quick

consensus, but, yeah, chewing tobacco would count since it's a tobacco

product. So, whenever you're doing that screening, it's important to look at

all routes that tobacco may be used to meet the intent of the measure. Does

that help? I'm going to take that as a yes. Thanks.

Okay. Great. Thank you. All right. Next question asks, “Are the measure specs

final for Performance Year 2019?”

This is Lisa Marie. Yes, the measure specs that have been released for 2019

are the final specs.

All right. Thank you. All right. Next question from the phone line is from

Rajitha Kamshatti. So, Rajitha, you may go ahead and ask your question.

Rajitha Kamshatti, you can go ahead and ask your question. All right, never

mind. Next, we will go on to Anita Erwin. Anita Erwin, you may go ahead and

ask your question.

Hi, this is -- this question is again about the tobacco use screening and I'm

still trying to get some clarification on this. So, if we have a patient that

chews tobacco in real life, he chews tobacco, but when he comes in to -- for

-- to see his provider, if they only ask, "Do you smoke?" He's going to say,

"No." And then that's going to count that we've assessed his tobacco status,

and that will -- but we didn't ask about any other form of tobacco and he

really is a user and we've missed that. So, that doesn't make any sense to me

that that's going to be providing good care.

Yeah. This is a good question about the interaction and how the intent of the

measure sort of aligns or works within the flow of the interaction that you

have with the patient and the measure truly is intended to look at tobacco

use in all forms. And so, I know that the question can get tricky. I

understand interacting with the patients, they -- when you're -- depending on

how the question gets asked, they're going to give you a different response.

And I completely appreciate that nuance within that interaction with the

patient but I can just speak to the intent of the measure. And so the intent

truly is to look at all forms of tobacco use that you have that patient and

obviously, when abstractors are going to go back in and look to see if

screening was performed and if the patient was positive for tobacco use,

they're going to have to rely on the medical documentation that they find

within the chart. And so, you know, that's a question for the nuance of

assessment skill I would say that if the patient -- the question was, "Do you

smoke?" and the patient says, "No," but you understand that they chew, how

they would interact with the chart to document that. And so, again, that's

sort of a nuance and I can just speak to that intent that the measure is

truly looking for all types of tobacco use.

I believe it was last -- it was in 2018 and I remember on the weekly calls

early in the year when we – you know, during the time that we were actually collecting all the data, this topic was discussed ad nauseam and we were told

12

last year that if -- and the way I understood it was if we only documented

that we assessed for smoking, that it -- we could not use that. That would

not count for the numerator because we did not assess for all forms of

tobacco. So, we spent a whole lot of time this year redesigning our EHR to

ensure that we captured both forms of tobacco. But now this year, you're

saying, as long as you just ask for smoking, you're good.

So, no, I want to just clarify that that is a piece of it, but that's not

completely what I said. And so, what I'm saying is the intent of the measure

truly looks at all forms of tobacco use, non-specific question. And how you

framed that question as a clinician to the patient in that interaction can

get a little bit tricky in the way that you're getting or procuring that

information from your patient and then transcribing it into the

documentation. So, I am not saying that you should ask a specific question or

that the question of "Do you smoke?" is irrelevant, that's a relevant

question. But I'm saying that it could be broader, and I'm saying that the

intent of the measure is truly to assess for all forms of tobacco use

regardless of route, so inhalation, chewing, like, that's what I'm trying to

say. And I do appreciate that, you know, this has been a really -- it's been

hard to sort of translate into clinical flow, and I appreciate your feedback.

I will say that we do take these questions back to the measure steward and

this is how we get to this point of its clarification and guidance from the

steward. We do interact with them on these questions. Is that helpful? Or do

you -- should we open a help desk ticket to discuss further, would that be

helpful?

Okay. Great, thank you. We will let you know if another question from the

same line comes in. All right, your next question asks, “Can we do full

screening over the phone?”

Hi, this is Olga from the PIMMS team. So, the setting of the screening is not

restricted to an office setting and, yes, it can be completed during a

telehealth encounter.

Great, thank you. All right. Next, “What is the reporting period for

Promoting Interoperability?”

So, this is Lisa Marie. So similar to Quality reporting via the Web

Interface, it's from January 2nd to March 31st. So, that's also for

Improvement Activities and Promoting Interoperability. So, it’s all

performance categories that you’re required to submit data on, the submission

period is the same timeframe. There was another question with regards to the

test period. So, as we said earlier in the presentation, for this year, there

is not a test period for the Web Interface. So, the Web Interface will just

open promptly on January 2nd. And because you have a longer timeframe to

submit data, which is actually three months compared to previous years which

was eight weeks, we no longer have a test period since you have a longer time

frame to actually submit data. So again, there is no test period.

Great, thank you. All right. We’ve had a few more questions come in over the

phone line. So, Martin Genz, we are unmuting your line, you may go ahead.

All right, thank you. I'm going to go back to the PREV-10 question again. I'm

looking at a screenshot of slide 50 of the frequently asked questions. The

question is, “Do we need documentation that we screen for both smoking and

13

smokeless tobacco to meet the screening portion of the measure?” And the answer goes on to say, "No, per the measure steward, you do not need to

document the patient was screened for both smoking and smokeless tobacco for

the 2019 report." So, from what I hear, everything seems to be, you know,

it's talking in circles here. So, which is it -- do we need tobacco or just

smoking? And I think everybody has the same question. Thank you.

Yeah. I appreciate that. The queue has blown up a little bit for questions.

And again, it's -- the intent is, it's going to be for all types of tobacco,

so I guess if we're considering turning tobacco smokeless, the answer would

be -- that would be included, yes, so tobacco use in the form of -- I guess,

however you guys are interpreting as smoking and non-smoking tobacco. I'm

looking at my team here. Do you guys have any other thoughts on this,

additions?

This is Deb. I'm not sure if this is going to be very helpful or not. We

understand that in previous years, the guidance was, you needed to ensure you

were screening and asking the question, "Do you smoke?" And question number

two, "Do you use smokeless tobacco?" What the measure developer has provided

us for clarification is the intent of the measure is that you are screening

for tobacco use. But if you happen to ask, "Do you chew tobacco?" And the

patient says, "Yes, I do." And you documented, "Yes, you're a tobacco user,"

and you provide cessation intervention, you've met the measure. Let's say the

patient was always a smoker and so the provider happen to just ask, "Do you

smoke, are you still smoking?" And the patient says, "No, I don't." And you

have that documented in the medical record, you've met the intent of the

measure. The nuance that's changed is that you no longer have to show

specifically that you asked those questions. Clinically, you're probably

asking, or you may find it's most important to ask, "Are you a tobacco user?"

And that's covering both smoking and smokeless tobacco. But if your questions

are phrased in such a way that you only happen to be asking about one form of

tobacco use and you have that documented in the medical records then you pass

the measure. Does that help?

Possibly, I think this one's going to be discussed on a few more of these

calls, thanks.

Oh, sure. I'm sure it will be. Thank you.

Great, thank you. All right. We've gotten a few questions on the sample file,

so please can you clarify when the list of sample patients will be available

and how can you find it?

Hi, this is Ozlem. On January 2nd at 10:00 AM when submission period starts

for Web Interface, you will be able to access the Web Interface and download

your beneficiary sample file. Thank you.

And this is Kristin, just to clarify -- for ACOs, the patient ranking files

will be sent prior to the opening of the Web Interface. And the release of

the patient ranking files will be announced in upcoming ACO Spotlight

Newsletters with details on how to access it. Thank you.

Okay. Thank you. All right. Next--

Lauren, I know that--

14

Yup?

-- We're at 2:00. But I saw some other questions with regard to Web Interface

FAQs so I just want to address that. Yesterday, we released a direct

communication to all groups registered to the Web Interface with the link to

the posting of the Web Interface FAQs. Also, so that you're -- so you're able

to access them on the Resource Library, and if you received your email from

us that was sent out yesterday, the link to the document is there. Also, in

the Web Interface, as Ozlem show the -- you know, the navigation panel on the

left-hand side of the Web Interface, there is a listing for the FAQs. So,

you'll be able to access them actually in the Web Interface also. So, we just

want to highlight what those resources are.

Great. Thank you, Lisa Marie. All right. And just for clarification, this

webinar is scheduled until 2:30, so please stay on the line if you have a few

more questions.

Oh.

The next question does ask, "How do we know if a clinician meets a threshold

for Web Interface reporting versus MIPS reporting?"

Can you repeat that question?

Of course. It asks, "How do we know if a clinician meets a threshold for Web

Interface reporting versus MIPS reporting?"

So, the Web Interface requires that all measures are reported on and you have

to report on at least 248 consecutively ranked beneficiaries. If your pool or

sample is less than 248 for each measure, then you report on your total of

beneficiaries. So, the reporting requirements for the CMS Web Interface is

different for other submission types through Web Interface, so there's not a

threshold. So, as I noted, for Web Interface you report on all measures, and

report on at least 248 consecutively ranked beneficiaries, or if you have

less, you can report on all of them.

Hi, Lisa Marie. If I can add on to that, when you are reporting in the Web

Interface, there are indicators, various indicators to show your reporting

progress as you complete measures, or as you meet the minimum reporting

requirement for each measure, that measure will be indicated as a requirement

met and complete. So, the -- in additionally, you can also go to the report

section and you can see your progress and your status on completion in

various reports available within the Web Interface.

All right. Great. Thank you. Next question, we'll go back to the phone line.

So, Olivia Tucker, we'll go ahead and unmute your line and you may ask your

question.

Hi, thank you. My question is, when is the next webinar that will include us

to be able to ask questions about the hypertension measure? I think you had

stated that earlier but I missed it.

So, for -- that will be January 15th.

15

Okay. Thanks.

Okay. Great. Thank you. Next question is also from the phone line. It's from

Dominique Buhl. Dominique Buhl, we've unmuted your line. You can go ahead.

Oh, mine's already been answered. Thank you.

Great. Thanks for letting us know. All right. Next question asks, “Can you

get bonus points if you answer more than the required 248 consecutive

measures?”

This is Lisa Marie. So, if you report more than 248 consecutively ranked

beneficiaries, you do not get bonus points or it does not necessarily

increase your score. If you report more, you're welcome to, but you're not

required to. And if you do so, it doesn't provide bonus points. And it may

not necessarily increase your score.

Great. Thank you. All right. Just as a reminder, if you would like to ask

your question over the phone, please make sure that you are connected to

audio. And you may have to input your unique audio pin in order to ask a

question. Right. So next question asks, “What is the average turnaround time

to hear from QPP whether your skip reason is accepted or not?”

Hi, this is Kayte from the PIMMS Team. So that question is really dependent

on a couple of things. The first is how much information is provided

regarding the skip request when it's submitted. We shoot to have them

reviewed and resolved within three days, but there might be cases where we

need more additional information, or your specific case requires further

investigation. So, we anticipate about three days but just keep in mind there

may be situations where your response takes a bit longer.

All right. Great. Thank you. We'll go back to the phone line. So, we have a -

- a question from Amy Poteat. Amy, you may go ahead and ask the question.

Hi, I have a question regarding the bonus for uploading information. I would

like some additional information. If you're an ACO, is there an opportunity

to get those bonus points? I have not heard any information around that.

Hi, if you--

If you are referring—

Go ahead.

--to the end-to-end bonus points, you can earn them by using the Excel upload

functionality or the API functionality in Web Interface. Those are for the

end-to-end electronic reporting bonus points.

And that does apply to the ACOs and it applies to groups and virtual groups.

In regard to high priority bonus points, in the 2019 Final Rule it was

determined that those points would no longer be applied to groups and virtual

groups. But it is still applicable to ACOs.

16

Okay. All right. Great. Thank you for that. We have few more questions from

the phone lines so we will turn it to Michael Leivant. Michael, you may go

ahead and ask your question.

Hi. So last year there was a new function or report in QPP that showed data

irregularities. My question was, is that still available for this year? Is

that report downloadable like many of the other reports? And, are those

irregularities still optional in terms of us fixing them?

The data irregularities report is still available this year. That

functionality has not changed, and it will be available and will function as

it did last year.

And is it still optional that we fix it or is it requirement that all those

irregularities be fixed?

Correct. Data irregularities are not errors, so it is optional. It is just to

bring any data irregularity to your attention. It is at your discretion,

whether or not, you would like to fix that.

Okay. Great. Thank you. All right. Next question asks, “Regarding the HTN-2

measure, is the denominator including only patients who have had a visit

within the measurement period, and then those who have had blood pressure

controlled? Or is it any patient who had a -- sorry, diagnosis with HTN would

have to visit?”

Hi, so this is Kayte from the PIMMS Team. So, it would be patients with a

denominator eligible visit with the appropriate diagnosis. And then you would

use their most recent blood pressure during the measurement period. And I

believe RTI can speak more to the sampling process and criteria for that

measure.

Okay. We can go back to that as well. We have a question from the phone line

from Amanda Ballinger. So, Amanda, you may go ahead and ask your question.

Is it talking, or --

Amanda--

Hi, this is -- this -- sorry. This is obviously not Amanda, but same phone

line. A question with regards to the end-to-end reporting bonus. If we upload

information out of our EMR into the populated Excel file, and then also make

corrections via the Interface afterwards, is that still qualified for bonus

points?

Can you repeat your question?

Sure. So, with regards to the end-to-end reporting and bonus points

associated with that, if we are taking the sample file and then populating it

with EMR data out of our EMR directly, and then uploading that into the

Interface, and then also making corrections via the Interface to the sample

file, does that qualify for end-to-end reporting bonus points?

17

Once you use the Excel upload functionality to submit your data, you earn

bonus points. Later on, going back to the Web Interface and using the data,

Manual Data Entry functionality will not impact the bonus points you already

earned. So, you will still earn the--

Oh. Perfect. Thank you.

--Excel upload.

Great. Thank you. All right. Next question asks, “Are there only” -- oh. I

just lost it. Hang on just a moment. “Are there only specific CPT codes for

telehealth for false screening and influenza that can be reviewed with

beneficiary? Or is it basically any kind of -- sorry, conversation with

beneficiary where the information captured and documented in the EMR count?”

Hi, this is Angie from the PIMMS Team. Telehealth is not narrowly defined for

the purpose of collecting information to the numerator for the Web Interface

measures. The measures that do allow telehealth can be obtained over the

phone, email, et cetera. The medical record documentation is required to

support what is reported. But no, it isn't particular codes. It's just a

method by which it is obtained. Thank you.

Great. Thank you. All right. Next question is from the phone line. It's from

Mark Smith. So, Mark Smith, you may go ahead and ask your question. Mark

Smith, you may go ahead and ask your question. All right. So, we'll move

back. Another question asks, “If our ACO uses the Excel upload for some but

not all of the reporting, are we still eligible to earn the end-to-end bonus

points?”

That is correct. You can do partial Excel upload. And you will earn bonus

points for that Excel upload that was completed. It does not require full

file or it does not -- in order to earn bonus points, you can use combination

of these methods. It does not require that a hundred percent of your

submission was completed through Excel. So, you will still earn bonus points

for using the Excel upload functionality.

Great. Thank you. Going back to a previous question we have, “What is the

definition of a telehealth encounter, and is it a certain codes only?”

Hi, this is Angie from PIMMS. I think we just answered that. And I -- what

was the last part of the question regarding telehealth?

Does it pertain to certain codes only?

Okay. The answer is no. Again, it's -- certain measures do allow obtaining

the information during a telehealth encounter. But it does not have to be

billable, a Medicare covered billable encounter code, just a method by which

the information is obtained. And it must be documented in the medical record

to support what's reported for a measure. Thank you.

Great. Thank you. All right. I think we have Mark Smith back on the line. So,

Mark, you may go ahead and ask your question. All right. Nevermind. We'll try

from Lisa Tranausky. Lisa, I've unmuted your line. You may go ahead.

My question was already answered.

18

All right. Great. Thank you. All right. Next question asks, “Does a PHQ-9 not

count for adolescents?”

Hi, this is the PIMMS Team. So -- okay. So yeah, the PHQ-9 can be used. It's

a modified PHQ-9 that's specifically for children.

All right. Great. Thank you. All right. One more question from Michael

Leivant. Michael, you may go ahead and ask your question.

Thanks. So, regarding all these kind of measure updates that have been

discussed today and will be discussed in the future. Have those changes been

made to the measure logic that CMS releases to EMR systems? So, for instance,

our EMR system has work with and received files from CMS. It really explains

the logic behind these measures so that they can build necessary reports for

us. Have those been updated to reflect the things that we've just talked

about today and others?

Hi, this is Kayte from the PIMMS Team. So, the coding document Release Notes

do outline all of the coding changes and that would impact subsequent logic

changes to the measure. So those are available in that Supporting Documents,

zip file on the Quality Payment Program Resource Library, along with the

Release Notes to the narrative specifications. Thank you.

Great. Thank you. All right. We have another question on the HTN-2 question.

Can you please clarify the sampling criteria?

Hi, this is Kristin from RTI, and I think this goes back to a previous

question. And just to clarify, in order for beneficiaries to be eligible for

any measure in the sample they need to have had two visits within the ACO or

group within the measurement period. And then we look for a diagnosis of

hypertension within the first six months in the year prior to the measurement

period, and then the encounter codes for the hypertension measure in --

within the same timeframe.

Okay. Great. Thank you. All right. One more question from the phone line from

Renee McCord. Renee, we've unmuted your line. You may go ahead.

Hi, there. You had mentioned one of the slides for measure MH-1 that there

was a difference between the PHQ-A and the PHQ-M. Can you clarify if either

can be used for the measure reporting?

Hi, this is Kayte from the PIMMS Team. So, for 2019 reporting, the PHQ-9 or

PHQ-9M may be used for the measure. The PHQ -- excuse me. Although the PHQ-9

is used and endorsed by several societies, this modification of the PHQ-9M

has not been formally validated. So, for 2019, the tool has not reached --

excuse me. The measure steward decided to allow both tools, PHQ-9 and PHQ-9M

for adolescents. And do not district tool use by age. Thank you.

Okay. Great. Thank you. All right. Next questions asks, “Can you please

elaborate on the depression screening measure?” All right. Just to re-ask. Can you please elaborate on the depression screening measure?

Hi, this is Kayte--

19

Kayte -- okay, sorry. Go ahead, Kayte.

I was going to say, I think whoever submitted that question, we might need a

little bit more information on what your specific inquiry is regarding that

question. So, if we could just get a little bit of clarification, we can

address your question in more detail. Or, if you would like to, you can

submit a help desk ticket. Thank you.

Okay. Looks like they're calling into the phone line. So Rajitha Kamshatti,

you may go ahead.

Hi, can you hear me?

Yes, loud and clear.

Yeah. Hi, this is Rajitha, so I have a question that is regarding the

depression screening. In one of the slides you mentioned we need to look for

the tools that we used, the screening tools, the names of those and it should

be documented in the EHR. So, do we have to look for those? If they're, like,

they're not documented, can we still consider them or not? Or could we just

score, like, looking at the scores?

Hi, this is Kayte from the PIMMS team. So, the direction for 2019 PREV-12, in

regards to required documentation, is aligned with what is in the measure

specifications. So, per page six of the specification, the name of the

appropriate standardized depression screening tool must be utilized and

documented in the medical record. So, if just the questions are available in

the EMR, that's not sufficient. It must have the name of the screening tool

utilized. Thank you.

Okay, thanks.

Great. Thank you. All right. Your next question asks, “Are there any changes

to Excel templates for 2019? And if so, is there a document that outlines

them?”

There are several changes to the template. There are obviously measure

changes and few other changes that you can easily identify by comparing the

file from last year to this year. Excel template has been published on the

QPP Resource Library. So, you could go to the QPP Resource Library and

download a copy of the Excel template. But at this time, we do not have a

document that outlines the changes compared to the last year. Thank you.

All right. Great, thank you. All right. We have another question from the

phone line from Debby Smith. So Debby, you may go ahead.

Yeah. Hi, can you hear me?

Yup. You may go ahead.

Oh. I just wanted to clarify the skip process. I’m reading through the

questions chat and I'm a little -- I just want to make sure I have it

correct. The skip process for Other CMS Approved Reasons, that's only needed

for reasons outside of a standard exclusions exemptions process would be or

is that for all skips?

20

Hi, this is Laura. That is correct. It is only for no Other CMS Approved

Reasons. All the other skip request reasons such as denominator exclusion,

those are standard as we've recorded before.

And they're submitted right to the spreadsheet uploaded through QPP?

Correct. You can select denominator exclusion as an answer for if the patient

qualified for the measure in the Excel template and upload.

Great. Thanks.

No Other CMS Approved Reason is reserved for unique cases that do not go with

other skip reasons.

Great. Thank you.

All right. Thank you. Next question asks, “If we are in our first year, pay

for reporting, do we submit MIPS as planned or do we have to submit to the

Interface?”

From the Shared Savings Program. If this is an ACO, which I'm presuming it

probably is because of the question about case reporting, then the

requirements for submitting for the Shared Savings Program, you'd have to

submit your measures through the CMS Web Interface. But it would actually be

good if you could actually give us a little bit more information on that

question, please.

Okay, if you're able to raise your hand, we'll go ahead and unmute you. And

in the meantime, we have a question from Melissa Reed, I believe on flu and

telehealth encounter. So—yeah, so, can you please just clarify to her

correctly that you cannot take flu in a telehealth encounter.

Hi, this is Jamie with PIMMS. You can go ahead and take an assessment of flu

on -- during a telehealth encounter. Thanks.

Thank you, Jamie.

All right. So, going back to the previous question. Brittany, we've unmuted

your line so you can elaborate.

Can you guys hear me?

Yes, you may go ahead.

Okay. So, we were approved as an ACO on July 1. And we have our providers

reporting MIPS for 2000 -- well, year 2018. But for the rest of this year, we

were just making sure that we don't have to submit for the previous year on

the Interface. So that will be all for 2019. It's not going to be for 2018,

correct?

This is Sarah from the Shared Savings Program. So, for the -- your ACO in

2020, you would be reporting for -- it's going to be a 2019 through the CMS

Web Interface through your ACO participants.

21

Okay. Great. Thank you. All right. So, we got about five minutes left. So,

we'll take a few more questions. We have one more in the phone line from Sean

Shillinger. So, Sean, you may go ahead.

Hi. I just wanted to clarify the question that was asked about a PHQ-2or PHQ-

9 resembling a PHQ-2 or 9 without being named. And the answer was, it must be

named. This contradicts a QPP response I got last year saying as long as it

resembles it exactly, per the wording, that it would count.

Hi, this is Kayte from the PIMMS Team. So, yes, the updated items for 2019

recording the lines with the measure specifications, and again states that

the name of the tool must be documented in the medical record, and that can

be -- that reference can be found on page 6 of the measure specification.

Okay. Great. Thank you. All right. Next question asks, so “Please confirm

that there's no document this year that compared to 2018 measurements --

measures, sorry, to 2019 measures and/or any updates for measure.”

Hi, this is Kayte from the PIMMS team again. So, there are documents out

there that do outline the changes within the narrative specifications and as

well as the coding documents. So those are found on the Quality Payment

Resource Library within the 2019 CMS Web Interface Supporting Documents. And

again, there are Release Notes outlining changes from 2018 to 2019 for the

narrative specs as well as the coding documents.

Okay. Great. Thank you. All right. We'll take one more phone question from

Christina Tomaselli. So, Christina, you may go ahead.

Hi. I just had a question about the depression measure clarification. I was

looking in the specification, and it looks like for follow-up on a positive

screening that they do not take a negative PHQ-9. So, if you do a PHQ-2 and

it's positive, in previous years, we were given guidance that you could

accept a PHQ-9 done on the same day that was then negative. But it looks like

that was taken away, that option.

Hi, this is Kayte from the PIMMS Team. So, we're currently reviewing this

issue. And we would just ask that any PREV-12 questions be directed to

qpp@cms.hhs.gov. Thank you. Hopefully, that was the right email address.

[ Laughing ]

Great. Thank you. So, next question asks, “Can you please clarify if the PHQ-

M and the PHQ-A be used for the MH-1 measure or are you stating that it has

to be PHQ-M?”

Can you please repeat the question?

Of course. It asks, “Can you please clarify if the PHQ-M and the PHQ-A be

used for the MH-1 measure or are you stating that it has to be PHQ-M?”

So, either the PHQ-9 or PHQ-9M may be used for the 2019 MH-1 measure.

Okay. Great. Thank you. All right. Looks like that's all the time we have

today for questions. So, thank you very much. And Lisa Marie, we'll turn it

back to you to conclude the webinar.

22

Great. Thank you. Again, I want to thank everyone for your participation in

answering your questions. Unfortunately, we weren't able to get to all of the

questions. But if you have any questions remaining, please submit your

questions to the Quality Payment Program Service Center, and we'll address

those questions. Again, our next webinar will begin on January 1st*2. And we

look forward to having you all join us. Again, thank you for joining us today

and have a great day. Thank you everyone.

2 The next webinar will be held on January 15th.

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