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2022 MIPSPreparing for the New YearJanuary 12th, 202212:00PM PT
Kathryn Rigda, PTDirector of Clinical ProductManagementKaitlin NolteTechnical Compliance Manager
Agenda Announcements and 2021 Housekeeping2022 Scoring changes2022 CQM UpdatesImprovement Activities and Promoting InteroperabilityRaintree setup - new MIPS Management ToolMyMipsScore Registry pricing optionsOpen Q&A
Announcements2021 Housekeeping and MyMipsScore Submission
2021 MIPS Automatic Exception due to COVID-19 CMS Automatically applies this toALL individual eligible clinicians if nodate is submitted for 2021. However, if data is submitted, thatsubmission process will override theexception. Group Submission is optional,through an opt-in process, and willoverride this exception.
MIPS 2021 Submission MyMipsScore Registry2021 MIPS Submission Window: January 1, 2022 - March 31, 2022Data Entry Deadline: February 28th, 2022“Submit” button available on Monday, January 17th 2022 for those ready to initiate process - this will trigger Score Preview before FinalSubmission to CMS
MIPS 2021 Submission MyMipsScore RegistryCustomer Checklist:1.Validate TIN and all Provider NPIs accuracy (this should have already been completed)2.Verify MyMipsScore Settings are appropriate for practice size, participation, etc.3.Enter all required information for performance categories (IA and PI)4.Select “Submit” - this will initiate process of showing a Score Preview5.Raintree staff will communicate before final CMS Submission takes place on your behalf
MIPS 2022Program Overview and Scoring Updates
2022 MIPS Final Rule By law, the Quality and Costperformance categories must be equallyweighted at 30% beginning with the2022 performance period Promoting Interoperability is finalized at25% and Improvement Activities remainthe same as 2021 at 15%*There are two new MIPS Eligible ClinicianTypes: Clinical Social Workers Certified nurse midwives
2022 MIPS Final RuleMinimum Performance Threshold and Payment Adjustments 75 points minimum performance threshold MIPS eligible clinicians will continue to meetthe current data completeness threshold of70% (e.g., must report at least 70% of eligiblecases for each Quality measure) for the 2022and 2023 performance periods.Exceptional performance 89 points This means, the requirement to achieve afinal MIPS score of at least 75 points toavoid a MIPS penalty is challengingData Completeness2022 performance year is the last year for anadditional MIPS adjustment for exceptionalperformanceMax payment adjustments for 2022 remain the sameat /- 9% If you are eligible and do not participate in2022, you will receive a negative paymentadjustment of -9% in 2024Visit the QPP Website
2022 Clinical Quality Measure (CQM’s)Measure Removal, Additions, and Coding Updates
Measure Changes for 2022 - Therapy SpecificMeasure TitleMeasure DescriptionCQM #ChangeFalls: Risk AssessmentPercentage of patients aged 65years and older with a history offalls that had a risk assessment forfalls completed within 12 months154RemovedBody Mass Index (BMI) Screeningand Follow-UpPercentage of patients aged 18years and older with a BMIdocumented during the currentencounter or within the previoustwelve months AND who had afollow-up plan documented if mostrecent BMI was outside of normalparameters.128Removed from claims-basedreportingUrinary Incontinence: Plan of Carefor Urinary Incontinence in WomenAged 65 Years and OlderPercentage of female patients aged65 years and older with a diagnosisof urinary incontinence with adocumented plan of care for urinaryincontinence at least once within 12months.50AddedRehabilitative Therapy Referral forPatients with Parkinson’s DiseasePercentage of all patients with adiagnosis of Parkinson’s Diseasewho were referred to physical,occupational, speech, orrecreational therapy once during themeasurement period.293Added
2022 Therapy Measures 226: Tobacco: Use: Screening and Cessation Intervention 282: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 283: Dementia: Functional Status Assessment127: Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear 286: Dementia: Counseling Regarding Safety Concerns 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up 288: Dementia: Caregiver Education and Support 130: Documentation and Verification of Current Medications in the Medical Record 293: Parkinson’s Disease: Rehabilitative Therapy Options 134: Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan 478: Functional Status Change for Patients with Neck Impairments 155: Falls Risk Plan of Care 181: Elder Maltreatment Screen and Follow-Up Plan 182: Functional Outcome Assessment 217: Functional Status Change for Patients with Knee Impairments 218: Functional Status Change for Patients with Hip Impairments 219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments 220: Functional Status Change for Patients with Low Back Impairments 221: Functional Status Change for Patients with Shoulder Impairments 222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments 50: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women aged 65 years andOlder 126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: NeurologicalEvaluation
Improvement Activities and Promoting InteroperabilityThe Performance Categories you forget about
Improvement Activities Reporting Requirements Report 2 to 4 improvement activities, depending on weight, to receive maximumscore of 40 points in this Performance Category: Medium Weighted Activity - 10 points High-Weighted Activity - 20 points Clinicians, groups, virtual groups, and APM Entities with certain special statuses(small practice, rural, health professional shortage area, or non-patient facing) earn 2times the points for each activity. Plan to implement each improvement activity for a minimum of one continuous90-day period, unless otherwise noted, in calendar year 2022Improvement Activity WeightStandard ScoringSpecial Status ScoringMedium-weighted Activity10 points20 pointsHigh-weighted Activity20 points40 points
Improvement ActivitiesNew for 2022: Create and Implement an Anti-Racism Plan (IA AHE 8) Implement Food Insecurity and Nutrition Risk Identification andTreatment Protocols (IA AHE 9) Implementation of a Trauma-Informed Care (TIC) Approach to ClinicalPractice (IA BMH 11) Promoting Clinician Well-Being (IA BMH 12) Implementation of a Personal Protective Equipment (PPE) Plan(IA ERP 4) Implementation of a Laboratory Preparedness Plan (IA ERP 5) Application of CDC’s Training for Healthcare Providers on LymeDisease (IA PSPA 33)
Improvement ActivitiesUsed Most Frequently: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who HaveReal-Time Access to Patient's Medical Record (IA EPA 1) Use of Telehealth Services that Expand Practice Access (IA EPA 2) Use of Certified EHR to Capture Patient Reported Outcomes(IA BE 1) Regularly Assess Patient Experience of Care and Follow Up onFindings (IA BE 6)Improvement Activity Inventory List on QPP Website
Promoting Interoperability Reporting RequirementsThe following clinician types OR special status, are automatically exempt from this Performance Category: Clinical Social WorkerPhysician AssistantsNurse PractitionersClinical Nurse SpecialistsCertified Registered Nurse AnesthetistsRegistered Dietitians or Nutrition ProfessionalsPhysical TherapistsOccupational TherapistsClinical PsychologistsSpeech-Language PathologistsQualified AudiologistsSpecial Status: Small Practices (NEW)Ambulatory Surgical CenterHospital-basedNon-Patient FacingNote: With an automatic exception, your PIcategory weight is re-weighted to Quality.Even if you are exempt, you can choose toopt-in and submit data in this category.The re-weighting will be cancelled anddata will be scored against Final Score.The flexibility of opting-in may beadvantageous to maximize your potentialFinal Score.
Promoting Interoperability CEHRT and Measure RequirementsCEHRT Functionality: Raintree and MyMipsScore CEHRT ID: 0015EUM31NTK6S490-day reporting requirementMeasure Objectives: Security Risk Analysis Must complete during calendar yearInformation Blocking AttestationSAFER Guides Attest Yes or No to conducting an annual self-assessment using the High-Priority Practices Guide found here The High Priority Practices SAFER Guide identifies “high risk” and “high priority” recommended safety practicesintended to optimize the safety and safe use of EHRs. You will do this in partnership with Raintree.e-Prescribing If you do fewer than 100, you can take exclusionHealth Information Exchange Connect to an HIE for patient data exchange Send a CCDA via Direct Method - if you do more than 100 in 90-days Receive a CCDA via Direct Method - if you do more than 100 in 90-daysPublic Health and Clinical Data Exchange Must report Immunization Registry Reporting or Electronic Case ReportingProvider to Patient Exchange Patient portal access Denominator: patient has a visit Numerator: Unique patients that have an email address and a password on file Password can be either a temporary password that was provided to patient or a patientselected password This process verifies that your office did send the welcome letter to patientwith a way to access the patient portal, should they choose to do so* If you opt-out of e-Rx, Send/Receive, and Public Health, the points reweight to Provide Patient Access.
Raintree Setup and ConfigurationMIPS Management Tool and Package Updates
2022 MIPS Measure Configuration If you have scheduled maintenance and are on 2020.3 orhigher, you should have received the necessary updatesfor 2022. If you do not have scheduled maintenance or onan older version, please contact Raintree Support. Cases have been created for clients that havepreviously reported MIPS. Updates include: CPT and ICD-10 coding edits; measurerequirements from spec sheets; and quality measurecollection requirements. NEW MIPS Management Tool (see screenshot to left) Select 2022 from Measure Year drop-downLocate measure in left-hand pane you wish tocollect data onSelect Add Collectable in center paneOnce selected, the measure will be available inright-hand pane for collection in 2022
2022 MIPS Measure Configuration Configuration for each measure can also now becompleted in this screen (see screenshot) Verify reporting Date RangeInclude/Exclude collection Note Type(s)Enter discipline informationSelect required reporting links for questionnaires orscreening toolsNo need to do anything in EMR Plug-In; the newManagement Tool will activate needed templatesautomatically!
MyMipsScore RegistryGeneral Overview and Pricing Options for 2022
MyMipsScore Qualified Registry under CMSMyMipsScore offers a completeMIPS solution to understand MIPS,calculate MIPS score, maximizeMIPS payment adjustment, andsubmit MIPS data to CMS.https://www.mymipsscore.com/
MyMipsScore Qualified Registry Pricing for 2022Pricing is being finalized for Performance Year 2022 and clients will be notified once available.There likely will be marginal changes, if any, from 2021 pricing.https://www.mymipsscore.com/
Open Q&AKaitlin Nolte knolte@raintreeinc.comKathryn Rigda krigda@raintreeinc.com
MIPS 2022: Preparing for the New YearThis session has been recorded and will be available on our User Groupsite once it has rendered.Thank you!
final MIPS score of at least 75 points to avoid a MIPS penalty is challenging Exceptional performance 89 points 2022 performance year is the last year for an additional MIPS adjustment for exceptional performance Max payment adjustments for 2022 remain the same at /- 9% If you are eligible and do not participate in
