MIPS 2022
MIPS Exception 2022
How to check MIPs participation status:
Go to this website and enter your 10-digit National Provider Identifier (NPI) number to view your QPP participation status by performance year (PY).
The website: https://qpp.cms.gov/participation-lookup
Hardship Exceptions
Can I Apply for an Extreme and Uncontrollable Circumstances Exception?
Yes. The MIPS EUC Exception application period for PY 2022 is now available and applications can be submitted through 8 p.m. ET on December 31, 2022. If you believe you have been affected by an extreme and uncontrollable circumstance (such as the PHE triggered by the COVID-19 pandemic), you can apply for this exception whether reporting traditional MIPS or the APM Performance Pathway (APP).
Extreme and uncontrollable circumstances are defined as rare events entirely outside of your control and the control of the facility in which you practice.
These circumstances would:
- Cause you to be unable to collect information necessary to submit for a MIPS performance category;
- Cause you to be unable to submit information that would be used to score a MIPS performance category for an extended period of time (for example, if you were unable to collect data for the quality performance category for 3 months), and/or;
- Impact your normal processes, affecting your performance on cost measures and other administrative claims measures.
Is There an Instance When the Extreme and Uncontrollable Circumstances Exception is Automatically Applied?
Yes. MIPS eligible clinicians who are located in a Centers for Medicare & Medicaid Services (CMS) designated region that has been affected by an extreme and uncontrollable event (such as FEMA-designated major disaster) during PY 2022 receive the automatic extreme and uncontrollable circumstances exception. We identify qualifying events through the QPP Listserv. Subscribe at the bottom of any page on the website.
The automatic extreme and uncontrollable circumstances policy does not apply to group or virtual group participation.
MIPS eligible clinicians identified as affected by the automatic extreme and uncontrollable event will have all 4 MIPS performance categories reweighted to 0% of their final score, unless they submit data for 2 or more performance categories. These clinicians are automatically identified and don’t need to submit an exception application.
If you qualify for the automatic exception and have an approved exception application, the performance category reweighting from the automatic exception will supersede any performance category reweighting approved through the application.
How Do I Apply?
You need a HCQIS Access Roles and Profile (HARP) account to submit a MIPS EUC Exception application. Once you sign into QPP with your HARP credentials, click ‘Exceptions Application’ on the left-hand navigation and then select ‘Extreme and Uncontrollable Circumstances.’
For more information on how to obtain a HARP account, refer to the Register for a HARP Account document in the QPP Access User Guide.
You can submit a MIPS EUC Exception application for PY 2022 through 8 p.m. ET on December 31, 2022
How Do I Know If I’m Approved?
You'll be notified by email if your request was approved or denied. You can also check the status of your application by signing into QPP. If approved, this will also be added to your eligibility profile in the QPP Participation Status Tool on a rolling basis. If your application is approved at the end of the performance year, it may not appear in the QPP Participation Status Tool until the submission window is open in 2023.
What Happens If My Application is Approved?
If your application is approved, you don’t have to report for the requested MIPS performance category or categories, and those categories will be reweighted.
Can I Still Submit Data?
Yes. Whether you qualify for automatic reweighting or have an approved exception application, you can still report data. If you submit data for 2 or more MIPS performance categories, you’ll receive a final score based on your performance in these categories.
What about APM Entities?
APM Entities participating in MIPS APMs can submit a MIPS EUC Exception application with some differences from our existing policy for individuals, groups, and virtual groups:
- APM Entities are required to request reweighting for all performance categories
- At least 75% of the MIPS eligible clinicians in the APM Entity will need to qualify for reweighting in the Promoting Interoperability performance category
- Data submission for an APM Entity won't override performance category reweighting
You will be notified by email if your request was approved or denied. You can also check the status of your application by signing into QPP. If approved, this approval will also be added to your eligibility profile in the QPP Participation Status Tool on a rolling basis. If your application is approved at the end of the performance year, it may not appear until the submission window is open in 2023. APPLY NOW
Who has to Report for MIPS for 2021?
Physicians, Physician Assistants, Nurse Practitioners, Clinical Psychologists and Clinical Social Workers who meet the eligibility status. Check your eligibility status here: https://qpp.cms.gov/participation-lookup
Clinical social workers and small practices qualify for automatic reweighting of the Promoting Interoperability performance category beginning with performance year (PY) 2022.
Performance Categories:
Quality
Promoting Interoperability
Improvement Activities
Cost
30%
25%
15%
30%
Reporting Period by Category:
Quality
Promoting Interoperability
Improvement Activities
Cost
365 days
90 days continuous-during the calendar year
90 days continuous-during the calendar year
You don’t need to submit data for the cost performance category. Cost measures are evaluated automatically through administrative claims data.
Penalty for not reporting
-9% Medicare reductions in 2024
Points required to avoid a negative adjustment
Minimum total score from all categories needed to avoid 2024 penalty: 75 points
Is There Automatic Reweighting for Certain Clinician Types and Special Statuses?
Yes, for certain clinicians and groups, the Promoting Interoperability performance category will be automatically reweighted to 0%. This means you don’t need to submit Promoting Interoperability data and the performance category’s 25% weight is generally redistributed to the quality performance category
Special status reweighting
If you are confused do not worry there are places you can get help.
Help from CMS
Small practices can receive consultation help from CMS at the link below:
Or call 1-866-288-8292
or
The cost of a MIPS consultation with ICANotes is $500.00 for 90 minutes.
EHR Certification
ICANotes is a 2015 edition CEHRT which is required for 2021 performance year. This is our certification number: 0015EZX9#QK9QC1
Getting Started in ICANotes
MOST IMPORTANT STEP
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.
Ask ICANotes staff to enable the following settings for you if you have never reported before:
- 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.
Step 2: Turn on Settings in the Chart Room
- Go to the Chart Room.
- Click on the drawer labeled Settings & Directories.
- 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.
- Click the Options Tab on the Specific to Individual tab.
- 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 2022.
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 up to 15 bonus points for submitting a yes response for the optional measure, Query of Prescription Drug Monitoring (PDMP).
You can earn 10 bonus points submitting a yes response for the optional measure, Query of Prescription Drug Monitoring (PDMP).
You can earn 5 bonus points for submitting a yes response for one of the optional Public Health and Clinical Data Exchange measures (Public Health Registry Reporting, Clinical Data Registry Reporting, or Syndromic Surveillance Reporting).
You can earn 5 bonus points for submitting a yes response for one of the optional Public Health and Clinical Data Exchange measures (Public Health Registry Reporting, Clinical Data Registry Reporting, or Syndromic Surveillance Reporting).
CMS list of all MIPS 2022 Promoting Interoperability objectives is at:
Promoting Interoperability
25% of your total score
Promoting Interoperability – (formerly ACI)– 25% of your total score
Report on any 90 days in 2022.
No significant changes to PI measures for 2022. All measures must be reported on via numerator/denominator, or yes/no submission even if an exclusion is taken.
CMS list of all MIPS 2022 Promoting Interoperability objectives is at:
2022 Promoting Interoperability Objective and Measure Set Table
Promoting Interoperability Scoring
Total Possible Points for Each 2022 Promoting Interoperability Measure?
Objective: Security Risk Analysis
Do this HIPAA Security Risk Analysis within your own practice in the 2022 calendar year.
Required: No points assigned but it is a Reporting requirement – you will answer yes/no
Resources for Security Risk Analysis
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.
In addition to submitting measures, clinicians must:
- 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
Objective: Health Information Exchange
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.
Measure 2: Support Electronic Referral Loops By Sending Health Information
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.
Measure Score: Up to 20 points
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 2022 even if you take exclusions.
Objective: Public Health and Clinical Data Exchange
- Measure: Immunization Registry Reporting--REQUIRED
- Measure: Syndromic Surveillance Reporting
- Measure: Clinical Data Registry Reporting
- Measure: Public Health Registry Reporting
Improvement Activities
Improvement Activities - 15% of your total score in 2022
CMS list of all MIPS 2022 Promoting Interoperability objectives is at:
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.
Provide 24/7 Access
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.
DrFirst Measure Reporting (Rcopia4)
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.
- Under MU REPORT TYPE, choose Stage 2.
- Choose the provider from the PROVIDERS dropdown menu.
- Select Date Range under Date.
- Select the Start Date (10/1/2019).
- Select the End Date (12/31/2019).
- Click the Create Report button.
- Take note of your results.
- 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
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)
- Ensure that the MIPS tab is selected.
- Select the provider(s) by choosing from the checkbox list.
- (Optional) Choose a site from the dropdown menu.
- The reporting period is any 90 days in 2021 .
- 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.
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.
Click the Go button by the measure you want to view.
This will show the results of the selected measure
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, 2023, to March 31, 2023.
Need Help? / Contact Us
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.
( All information obtained from CMS via the https://qpp.cms.gov/ website.)
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