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Reg-ent℠ MIPS 2019 Reporting

Reg-ent℠ MIPS 2019 Reporting

Reg-ent is the MIPS reporting tool of choice for otolaryngologists. As a Qualified Clinical Data Registry (QCDR), Reg-ent accommodates reporting for all required MIPS 2019 performance categories, including Quality, Promoting Interoperability (PI)*, and Improvement Activities (IA). Reg-ent staff at AAO-HNSF and FIGmd (the registry's technical vendor partner) will work closely with your practice through the process of Quality measures mapping and measures selection, PI and IA data entry and attestations, and ultimately the submission to CMS.

MIPS Scoring:

The MIPS Score is based on performance in all four categories:

  • Quality (45%)
  • Improvement Activities (15%)
  • Promoting Interoperability (25%)
  • Cost (15%)

The formula breakdown is:

Points earned / Total Possible Points in Category * Performance Category Weight = Earned Points

The minimum amount of points needed to avoid the negative payment adjustment is 30 Points.

Those who score more than 75 points will be eligible for an additional positive payment adjustment (up to 7%) and may share in the pool of $500 million of funding available for the year. 

Small Practice Bonuses & Exceptions:

For 2019 CMS will add 6 measure points to the numerator of small practice's Quality Performance Category score as long as the small practice submits data to MIPS on at least 1 quality measure. The addition of the 6 measure bonus points generally represents 10% of the quality performance category score for small practices.  If a small practice is unable to meet the measure or meet the "data completeness" the practice will still receive 3 points for that measure. 

Small practices receive double points for reporting IA measures. A small practice can earn all the available points in the IA category by reporting two med weighed activities OR one high weighted activity.

Rural & Health Professional Shortage Areas Bonus:

Clinicians located in federally defined rural or Health Professional Shortage Areas (HPSA) will receive double points for reporting IA measures. Rural practice can earn all the available points in the IA category by reporting two medium-weighted activities OR one high-weighted activity.

Quality Measure Bonus Points:

Bonus points can be earned by reporting more than one high priority and outcome measure

  • For every additional outcome measure reported, 2 bonus points can be applied
  • For every additional high priory measure reported, 1 bonus point can be applied.

The cap amount for bonus points under quality is 6.

You can earn up to 10 additional percentage points on your quality score if your 2019 performance has improved as compared to 2018.

An improvement percent score is calculated by dividing the increase in the quality category score from 2018 to the 2019 performance period by the 2018 quality category score multiplied by 10 percent.

Additional bonus points can be earned for end-to-end CEHRT. For every measure you report for this opportunity, one bonus point will be added on.

MIPS Participation:

Participating in the Quality Payment Program: Overview for Clinicians for the 2019 Performance Year fact sheet, click here to view.

It is important to find out your eligibility status for the reporting year. You can verify this information on the CMS QPP Website, please click here to check your eligibility. Please also take time to view the CMS 2019 MIPS Participation and Eligibility Fact Sheet here!

Do you have an EHR? The Reg-ent registry wants to help your practice better prepare for integration. EHR vendors require different methods of data transfer based on where the data is stored and the method of data transfer. Both these factors impact your ramp-up time in different ways as well as the level of involvement required from your practice. For questions about your EHR integration capabilities, please visit our Reg-ent and EHR website here or feel free to contact a member of the Reg-ent Team by emailing reg-ent@entnet.org

To view the CMS 2019 MIPS Group Participation Guide please click here

For additional information regarding MIPS, please visit the QPP CMS website or click here to view the CMS QPP Quick Start Guide for MIPS 2019.

Reg-ent MIPS 2019 Promoting Interoperability (PI) Reporting

CMS has changed the name of the Advancing Care Information (ACI) category to the Promoting Interoperability (PI) category. Reg-ent participants can manually attest to PI related data and view and monitor their base score, performance score, and bonus points through the Reg-ent MIPS dashboard.

To view all of the PI measures, please see below:

In addition to submitting measures, clinicians must submit a “yes” to:

  • The Prevention of Information Blocking Attestation,
  • The ONC Direct Review Attestation, and;
  • The security risk analysis measure.

Please note, only practices that have an EHR that is certified to the 2014 or 2015 edition will be able to report the PI category. Paper-based practices will be unable to report PI measures. To identify your EHR edition, click here

Additional PI Resources:

CMS Factsheet on Promoting Interoperability Prevention of Information Blocking Attestation: Making Sure EHR Information is Shared

For practice who have questions regarding what criteria allows for an exemption status for the PI category, please see the following reasons below:

  • Insufficient internet connectivity: Clinicians who demonstrate that there were “insurmountable barriers” to obtaining internet infrastructure sufficient to submit data under the ACI category.

  • Extreme and uncontrollable circumstances: This includes events such as natural disasters, closure of a practice or a hospital, severe financial distress (such as bankruptcy or debt restructuring).

  • Lack of control over the availability of CEHRT: This includes situations where a practice is unable to access CEHRT for reasons beyond its control. This exception is granted if 50% or more of a clinician’s outpatient encounters occur in a location where they have no control over the health IT decisions of the facility, such as clinicians who practice in multiple sites, or if they primarily practice through another entity (such as a SNF).

  • Small practice: You must demonstrate that there are “overwhelming barriers” that prevent you from complying with the requirements of this category. CMS has said it will release more information about the application process for this exception later in the year.

  • Decertification of CEHRT: Eligible if the CEHRT used by a practice was decertified during 2018 or 2019. Clinicians must demonstrate in their application and with supporting documentation that they made a good faith effort to adopt and implement another CEHRT.

For details regarding the PI Hardship Exception Application, click here.

Reg-ent MIPS 2019 Improvement Activities (IA) Reporting

To earn full credit in this performance category, participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2019):

  • 2 high-weighted activities
  • 1 high-weighted activity and 2 medium-weighted activities
  • 4 medium-weighted activities

High-weighted activities receive 20 points and medium-weighted activities receive 10 points.

The Reg-ent registry contains all Improvement Activities offered by CMS for MIPS 2019 reporting and Reg-ent participants can review assigned points for each IA, make selections, review scores, and then submit to CMS through the Reg-ent MIPS dashboard.

To view the full list please click here.

Reg-ent 2019 Quality Measures

To view the full list of quality measures available through the Reg-ent Registry, please click here!

CMS Key Dates:

  • January 1, 2019: 2019 Performance year starts
  • March 31, 2019: First snapshot for QP determinations
  • June 30, 2019: Second snapshot for QP determinations
  • August 31, 2019: Third snapshot for QP determinations
  • October 3, 2019: Last day to begin the continuous 90-day performance period for the Improvement Activites and Promoting Interoperability performance categories.
  • December 31, 2019: Performance year ends
    1. QPP Promoting Interoperability Hardship and Extreme and Uncontrollable Circumstances Exception Applications deadline.
    2. Fourth snapshot date for full TIN APMs (Medicare Shared Savings Program) for determining which eligible clinicians are participating in a MIPS APM for purposes of the APM scoring standard
  • January 1, 2020: 2020 performance year starts
  • January 2, 2020: Data submission period for 2019 performance year begins 
  • March 31, 2020 Data submission for 2019 performance year close.

Please note, these dates are reflective of CMS's deadlines and not Reg-ent's.