Index

Sections

1. Who has to Report for MIPS for 2021?
   
2. Performance Categories
   
3. Penalty for not reporting
   
4. Points required to avoid a negative adjustment
   
5. Help from CMS
   
6. Small practices can receive consultation help from CMS at the link below
   
7. EHR Certification
   
8. Getting Started in ICANotes
   
9. Step 1: Request Group Rules - create a ticket and request MIPS settings be enabled. This was already done if you reported in a previous year.
   
10. Step 2: Turn on Settings in the Chart Room
    

Who has to Report for MIPS for 2021?

Physicians, Physician Assistants, Nurse Practitioners, Clinical Psychologists who meet the eligibility status. Check your eligibility status here: https://qpp.cms.gov/participation-lookup

Performance Categories

Reporting Period by Category: 

Penalty for not reporting

-9% Medicare reductions in 2023

Points required to avoid a negative adjustment

60 points

Exceptional performance bonus: 85

Help from CMS

Small practices can receive consultation help from CMS at the link below

https://qpp.cms.gov/mips/special-statuses?py=2021

Or call 1-866-288-8292

EHR Certification

ICANotes is a 2015 edition CEHRT which is required for 2021 performance year. 

Getting Started in ICANotes

• Meaningful Use Measures
• Patient Portal Sync
• Direct Messaging
• Always Generate CCDA

You can email this request to ticket@icanotes.com or call us at 443-569-8778. 

1. Go to the Chart Room.
2. Click on the drawer labeled Settings & Directories.
3. On the Personal Info tab, make sure the MU / MIPS / CQM field is checked (as shown in the screenshot below). This is a READ-ONLY field.

Turn On Clinical Decision Support Rules and Patient Education Material.

1. Click the Options Tab on the Specific to Individual tab.
2. Check the following boxes to allow the program to automatically prompt you to print these items:  

• Clinical Decision Support Rules
• Patient Education Material

You will not comply with these measures unless you check these boxes.

Promoting Interoperability - 25% of your total score

Report on any 90 continuous days of 2021.

All PI objectives including Public Health and Clinical Data Exchange must be reported on or Exclusions taken otherwise a 0 will be given for the entire PI category. You must report all required measures (submit a “yes”/report at least 1 patient in the numerator, as applicable, or claim an exclusion) or you will earn a zero for the Promoting Interoperability performance category.

Bonus Points

You can earn 10 bonus points for submitting a 'yes' for the optional measure, Query of Prescription Drug Monitoring (PDMP). 

CMS list of all MIPS 2021 Promoting Interoperability objectives is at:

https://qpp.cms.gov/mips/explore-measures/promoting-interoperability?tab=qualityMeasures&py=2021 

Hardships Exceptions

• Extreme and Uncontrollable Circumstances Exception which includes COVID-19 

• MIPS Promoting Interoperability Performance Category Hardship Exception

Information can be found at:  https://qpp.cms.gov/mips/exception-applications

 *(Exclusion if write fewer than 100 permissible prescriptions during performance period)

25% of your total score

Promoting Interoperability – (formerly ACI)– 25% of your total score

Report on any 90 days in 2021.

No significant changes to PI measures for 2021. All measures must be reported on via numerator/denominator, or yes/no submission even if an exclusion is taken.

CMS list of all MIPS 2021 Promoting Interoperability objectives is at:

https://qpp.cms.gov/mips/explore-measures/promoting-interoperability?tab=qualityMeasures&py=2021  

Clinical psychologists will automatically have their PI category reweighted to Quality category.

Objective: Security Risk Analysis

Do this HIPAA Security Risk Analysis within your own practice in the 2021 calendar year.

Required: No points assigned but it is a Reporting requirement – you will answer yes/no

Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308 (a) (1), including address the security (to include encryption of ePHI created or maintained by CEHRT in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306 (d) (3) and implement security updates as necessary and correct identified security deficiencies as part of the EP’s risk management process.

Go to https:/www.healthit.gov/providers-professionals/security-risk-assessment-tool for the Dept of Health and Human Services tool on completing a Security Risk Analysis 

https://www.healthit.gov/providers-professionals/security-risk-assessment-video 

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_SecurityRiskAnalysis.pdf 

• Submit a “yes” to the Prevention of Information Blocking Attestation,
• Submit a “yes” to the ONC Direct Review Attestation; and
• Submit a “yes” for the security risk analysis measure

 Objective: ePrescribing

Required 

Measure: e-Prescribing

Measure Score: up to 10 points

The higher the percentage of prescriptions written the more points earned for this measure.

Exclusion available: If prescriber writes less than 100 prescriptions in 90-day reporting period. If exclusion taken points will be added to Provide Patient Access.

Numerator: The number of prescriptions in the denominator generated, queried for a drug formulary and transmitted electronically using CEHRT. This is automatically calculated by ICANotes.

Denominator: Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the EHR reporting period; or Number of prescriptions written for drugs requiring a prescription in order to be dispensed during the EHR reporting period.

Bonus Points: Optional

Optional: Query of the Prescription Drug Monitoring Program (PDMP) – up to 10 points

 Required

 You may be able to take the exclusion for Measure 1 Health Information Exchange:

EXCLUSION Measure 1: Any MIPS eligible clinician who receives fewer than 100 transitions of care or referrals or has fewer than 100 encounters with patients never before encountered during the performance period.

 Or Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2021 would be excluded from having to report this measure.

 If exclusion taken points are assigned to Send portion of Health Information Exchange.

 Measure 1: Support Electronic Referral Loops by Receiving and Incorporating Health Information

 For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.

 The higher the percentage the more points received.

 Measure Score: Up to 20 points

 Numerator: The number of electronic summary of care records in the denominator for which clinical information reconciliation is completed using CEHRT for the following three clinical information sets: 1) Medication – Review of the patient’s medication, including the name, dosage, frequency, and route of each medication; 2) Medication allergy – Review of the patient’s known medication allergies and 3) Current Problem List – Review of the patient’s current and active diagnosis.

 Denominator: Number of electronic summary of care records received using CEHRT for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of transition care or referral, and for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient.

• Start a new Complete Evaluation

• Go to the Finish Initial tab.
• Click the Medication Reconciliation Button. 

• Click the Complete Eval is from Referral / Transition check box.

• Complete the Rx section on the Reconciliation Form.

• Click the + on the left side to add a medication under step 1 to open the fields to add a new medication.  

• Click Details if you wish to add more details to the prescription. Details button is only available when adding medications.

• Click the Submit button to add the medication to the column on step 3.

 Decide how to proceed with the medication:

• Continue – medication, dose, route, and timing remain the same
• Continue but change – the medication dose, route, and timing can be changed
• External provider Rx – used in an outpatient setting to document medications that another doctor prescribes
• Hold – used in an inpatient setting to hold a medication during the patient's admission

• When all of the medications have been added, click the Confirm button.

• Once confirmed, the medications will show on Medications in the work area. 

• Click on Return to Progress Note
• Finish the complete evaluation
• Compile the note. Must do this to get credit.

No medications to reconcile? If no medications enter the date on the bottom left of the screen. See the example below.

Note: This objective must be reported using the doctor’s user id to be counted in the reports.

You may be able to take the exclusion for Measure 2 Health Information Exchange:

EXCLUSION for Measure 2: Any MIPS eligible clinician who transfers a patient to another setting or refers to a patient fewer than 100 times during the performance period.

If exclusion taken points are assigned to receive a portion of the Health Information Exchange.

If exclusions taken for both Send and Receive portions of Health Information Exchange, the 40 points go to Provider to Patient Exchange.

 For at least one transition of care or referral to a provider of care other than a MIPS eligible clinician, the MIPS eligible clinician 1) creates a summary of care record using CEHRT; and 2) electronically exchanges the summary of care record.

Numerator: Number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.

Denominator: The number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.

If exclusion taken points are assigned to receive a portion of the Health Information Exchange.

If exclusions taken for both Send and Receive portions of Health Information Exchange, the 40 points go to Provider to Patient Exchange.

• Go to Psych PN, part 2 or the Finish Initial tab of your Complete Evaluation.
• Click on the Clinical Order Sheet button.

• Click the Referral/Consult button.

• Click the + New button.

• Fill out all the appropriate information.

• (1) Click the Save button,
• and then (2) click the Back button.

• Compile the note.

• Record the date you are sending the referral to the provider on the Preview screen for the compiled note.

• Click the eSent to Provider field. 

• Next, click Create Clinical Summary.

• Don't forget to Compile this Note.
• Go to upload.icanotes.com site to retrieve the summary, save, and send it to the provider using secure methods to protect PHI.
• Kno2 is the way to send this securely via DirectAddress. You can find your own DirectAddress in the Kno2 site: https://kno2fy.com/account/login/
• Contact ticket@icanotes.com or call ICANotes
• at 443-569-8778 to get help with a Kno2 account.

Note: This objective must be reported using the doctor’s user id to be counted in the reports.

Objective: Provider-to-Patient Exchange

Required – No exclusion available

Measure: Provide Patients Electronic Access to Their Health Information

(1) For at least one unique patient seen by the MIPS eligible clinician, the patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).

Measure Score: Up to 40 points

Numerator: The number of patients in the denominator (or patient authorized representative) who are provided timely access to health information to view online, download, and transmit to a third party AND to access using an application of their choice that is configured meet the technical specifications of the API in the MIPS eligible clinician’s CEHRT.

 Denominator: The number of unique patients seen by the MIPS eligible clinician during the performance period.

The patient must be able to access this information on demand, such as through patient portal or personal health record (PHR) or by other online electronic means.

While a covered entity may be able to fully satisfy a patient's request for information through VDT, the measure does not replace the covered entity's responsibilities to meet the broader requirements under HIPAA to provide an individual, upon request, with access to PHI in a designated record set.

Objective: Public Health and Clinical Data Registry Reporting

 Public Health Reporting required as follows:

Select at least two of the five Public Health and Clinical Data Exchange measures below and take an exclusion for each of the two. You must report on these to CMS portal in 2021 even if you take exclusions.

Objective: Public Health and Clinical Data Exchange

• Measure: Immunization Registry Reporting
• Measure: Syndromic Surveillance Reporting
• Measure: Electronic Case Reporting
• Measure: Clinical Data Registry Reporting
• Measure: Public Health Registry Reporting

Improvement Activities 

 Improvement Activities - 15% of your total score in 2021

CMS list of all MIPS 2020 Promoting Interoperability objectives is at:

https://qpp.cms.gov/mips/explore-measures?tab=improvementActivities&py=2021 

Do you have 15 or fewer providers in your practice?

Small Practice: Report on one high-weighted or two medium-weighted activities in a small practice or if your practice is in a rural area or a geographic health professional shortage area.

If you are with a larger practice, you would report on four medium-weighted or two high-weighted activities for a minimum of 90 days.

In a small practice, the clinician would earn a perfect score for Improvement Activities.

Improvement Activities relevant to behavioral health clinicians include:

Provide 24/7 access, Depression Screening (using an age-appropriate screening tool), Electronic Health Record Enhancements for Behavioral Health data capture, Tobacco Use, Unhealthy alcohol use (using an appropriate screening tool), Engagement of patients, family and caregivers in developing a plan of care. Go to qpp.cms.gov to see the full list of Improvement Activities.

The Provide 24/7 Access is a high-weighted activity and can be demonstrated easily by going in after practice hours. A small practice would earn the entire 15 points for Improvement Activities.

Select Reports/Audit Log and then take a screenshot of the Audit Log at that time. This then shows the clinician has accessed the program after hours.

For the 90 days take screenshots at the beginning of the 90 days, once in the middle and then at the end.  This shows that the EHR can be accessed at any time.

Improvement Activities is an attestation only category.

Keep these screenshots for 6 years in a “Book of Evidence” file in case of a future audit.

 Access DrFirst  (by Chart Room buttons, patient demographics, or note).

Click the Menu icon in the top left of the window, and select Reports from the dropdown menu.

Under Reports, choose the Meaningful Use Reports link.

1. Under MU REPORT TYPE, choose Stage 2.
2. Choose the provider from the PROVIDERS dropdown menu.
3. Select Date Range under Date.
4. Select the Start Date (10/1/2019).
5. Select the End Date (12/31/2019).
6. Click the Create Report button.

1. Take note of your results.
2. You are able to print the report by clicking the Printer icon.

If you are running a full report in ICANotes, you will need to run a report for each provider and add the numerators and denominators to get the sum for all providers.

MIPS Tracking Report

(Reports menu)

Reporting will be available from the Reports menu bar and choosing the PI MU / MIPS from the dropdown menu. 

(Promoting Interoperability MIPS tab)

(Promoting Interoperability Medicaid STAGE 3 2015 Edition tab labeled)

1. Ensure that the MIPS tab is selected.
2. Select the provider(s) by choosing from the checkbox list.
3. (Optional) Choose a site from the dropdown menu.
4. The reporting period is  any 90 days in 2021 .
5. Click the measure you want to report.

Inserting DrFirst (Rcopia 4) Measure Data

If you have obtained the numerator and denominator numbers from the DrFirst Measure Report (Rcopia 4), follow these instructions:

Go to 2) ePrescribing. Click the blue DrFirst link.

Insert the Numerator and Denominator data gathered from Rcopia 4.

Click the Go button to see the results for the ePrescribing measure.

 By clicking on the list link, you will be able to see a list of the Denominators.

All Measures Report

Follow these directions to run a report for all measures.

 Click the Go button by All Measures to get an overview of all the measures.

You may receive this error if you have not entered the DrFirst data retrieved following the DrFirst Measure Report (Rcopia 4) instructions. 

 Click OK to clear the popup window.

 This will show the results of all measures.

(Example of reporting for all measures)

Print Report

 Click the Print Report button.

Once the Print Preview window pops up, ensure the correct printer is selected and then click the OK button.

Individual Measure Reports

 Follow these directions for an in-depth look at an individual measure.

(Example of running Patient Electronic Access)

 Click the Go button by the measure you want to view. 

 This will show the results of the selected measure

(Example of Patient Electronic Access report)

Print Report

Click the Print Report button.

 Once the Print Preview window pops up, ensure the correct printer is selected and then click the OK button. 

 Keep a copy of your MIPS Tracking Report for six years in the "Book of Evidence" for your practice in case you are ever audited.

Where do you submit your MIPS performance data?

Go to qpp.cms.gov "Sign in" to register for the CMS portal in January 2022. You will submit data via the portal between January 1, 2022, to March 31, 2022.

 ICANotes now offers MIPS assistance. 

 Review this ICANotes MIPS documentation, then contact us at 866-847-3590 or sales@icanotes.com if you wish to schedule training. There is a fee involved.