2019 CMS Web Interface Quality Reporting for MIPS Groups and ACOs

CMS Web Interface Support Call

March 25, 2020

Disclaimer

This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently, so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

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Announcements

• The following documents are now available on the Quality Payment Program Webinar Library:

- CMS Web Interface Weekly Support Call: Session 2 (Recorded 01/22/2020)*

• Recording, Slides, Transcript

The slides within this Support Call were updated to correct an error identified on slide 13.*

- CMS Web Interface Weekly Support Call: Session 8 (Recorded 03/04/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 9 (Recorded 03/011/2020)

• Recording, Slides, Transcript

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Announcements

• NOTE: CMS Web Interface Submission Period Extended

- The deadline for the 2019 data submission has been extended to April 30, 2020.

• The submission period for the CMS Web Interface aligns with other submission types, and closes promptly at 8:00pm Eastern Daylight Time (EDT) on April 30, 2020.

• The CMS Web Interface will automatically accept your submission at the end of the submission period.

• The CMS Web Interface is accessible via the “Sign In” link on the Quality Payment Program website at https://qpp.cms.gov.

- Submit Your Data Early

• We encourage you to submit your 2019 MIPS performance period data in advance of the submission period deadline. Early submission will provide you with time to submit Other CMS Approved Reason requests, and complete the CMS Web Interface reporting requirements. 4

CMS Web Interface Key Dates

Announcement

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CMS Web Interface Support Calls

• Weekly Support Calls

- Although the deadline for data submission has been extended, this will be the final CMS Web Interface Support Call.

- Submitters are encouraged to contact the Quality Payment Program at qpp@cms.hhs.gov with any questions during the remainder of the submission period.

- Visit the QPP Webinar Library for all 2019 CMS Web Interface Support Call slides, transcripts, and recordings

• Website: https://qpp.cms.gov/about/webinars

Reminders - Other CMS Approved Reasons

• Other CMS Approved Reason skip requests must be submitted through the CMS Web Interface.

- Other CMS Approved Reason is a way to skip a patient attributed to a measure during Denominator Confirmation.

• Reserved for circumstances that are unique, and unusual. Please review the 2019 measure specifications thoroughly before submitting a CMS Approved Reason request.

• It is not necessary to request a CMS Approved Reason if:

• There an applicable denominator exclusion;

• There is an applicable denominator exception;

• The patient is “Not Qualified for Sample” (patient is deceased, in hospice, moved out of the country, or did not have Fee-for-Service (FFS) Medicare as their primary payer); or

• Prepopulated demographic information is not accurate (e.g., birthdate, gender, etc.).

• Once an Other CMS Approved Reason is submitted, additional information may be requested from the submitter. These requests will come in the form of an e-mail from PIMMSQualityMeasuresSupport@gdit.com. - The e-mail will be sent to the address entered by the submitter in the skip request.

- Please try and reply with the information requested as soon as possible.

- If you have questions regarding the status of a skip request your organization submitted, please contact qpp@cms.hhs.gov and include the skip request number in your inquiry.

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Reminders - Other CMS Approved Reasons

• Patients for whom an Other CMS Approved Reason is selected will be “skipped” and another patient must be reported in their place for the measure, if available.

• When a skip request is denied, the patient will remain incomplete and users must complete reporting on the patient.

• Note: All decisions are based on the information provided in the skip request. Please provide detailed information about why the patient should be skipped. If multiple requests for additional detail are unanswered, the request will move forward in the review process using the information initially provided. Once a decision has been issued, the request cannot be reopened.

• Submitting any requests for an Other CMS Approved Reason during the last days of submission could cause your request not to be processed. 2019 Other CMS Approved Reasons submitted after Friday, April 17, 2020 may cause your request not to be processed prior to the close of submission. Submit such request as soon as possible.

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Reminders

• 2019 CMS Web Interface Application Programming Interface (API) is available all year for testing in the Developer Preview Environment:

- For more information, please review:

• CMS Web Interface API Narrative Documents: https://cmsgov.github.io/beneficiary-reporting-api-docs/

• Swagger Documents: https://preview.qpp.cms.gov/api/submissions/web-interface/docs/

• Measures.json: https://preview.qpp.cms.gov/api/submissions/web-interface/metadata

• Schema.json: https://preview.qpp.cms.gov/api/submissions/web-interface/metadata/schema

• Google Group for the CMS Web Interface API: https://groups.google.com/forum/#!forum/cms-web-interface

• From February 1, 2020 to March 31, 2020, the Google Group will be accessible as read-only. Beginning April 1, 2020, this Google Group will no longer be accessible. Please visit qpp.cms.gov for information regarding Quality Payment Program requirements.

• For any support related issues, please contact the Quality Payment Program at qpp@cms.hhs.gov.

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FREQUENTLY ASKED MEASURE QUESTIONS

Presenter: Angie Stevenson, CMS Contractor

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Frequently Asked Measure Questions

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MeasureID

Question Answer

CARE-2 Is it acceptable to use fall risk documentation from any type of visit found within the EMR? For example, an emergency room visit, visit to a specialist, etc.?

The setting of the screening is not restricted to an office setting. The measure is not limited to a particular provider type. The measure allows a clinician with appropriate skills and experience to perform the screening.

CARE-2 We have a patient who is a double leg amputee. Is this an exclusion for Care-2 Falls for the 2019?

CARE-2 includes a denominator exclusion for patients who were assessed to be non-ambulatory at the most recent encounter during the measurement period (i.e., patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair).

CARE-2 If we are able to find documentation of the standing gait and balance being tested by (1) having the patient marching in place, as well as (2) advance step and return each foot (step backwards), is this sufficient testing to meet the numerator?

A gait or balance assessment meets the intent of the measure. Screening for Future Fall Risk includes any assessment of whether an individual has experienced a fall or problems with gait or balance. A specific screening tool is not required for this measure.

Frequently Asked Measure Questions

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MeasureID

Question Answer

HTN-2 Are blood pressures captured by a nurse or specialist accepted?

Yes. The blood pressure may be taken by any clinician theorganization considers qualified and for whom the eligibleclinician or group clinically manages.

HTN-2 If there is a HTN diagnosis in 2016 and no mention of it after that or about it being resolved, should that patient be confirmed in the denominator?

The denominator confirmation requires a diagnosis ofessential hypertension within the first six months of themeasurement period OR any time prior to themeasurement period but does not end before the start ofthe measurement period.

If there is medical record documentation that supportsthe diagnosis of hypertension resolved prior to the start ofthe measurement period (01/01/2019), you would notconfirm that patient for the denominator. However, if thediagnosis was active during the measurement period, youwould confirm the diagnosis.

Each organization is responsible for determining if their medical record documentation supports the appropriate diagnosis within the specified timeframe.

Frequently Asked Measure Questions

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MeasureID

Question Answer

PREV-6 How should we report PREV-6 if the patient refuses to have a colonoscopy or any other test, such as the FBOT?

The PREV-6 measure does not allow a denominator exclusion or exception for patients who refuse colon cancer screenings. If the colorectal cancer screening for the patient is not current during the measurement period you must report that that the quality action was not performed.

PREV-7 If we have a patient who is in Hospice but CMS has prepopulated the flu shot in the sample, do we leave it as eligible since CMS has already found the vaccination?

No. Since the hospice exclusion is at the patient confirmation level you should select that option. For the 2019 PREV-7 measure this can be found on page 6 of the posted measure specification.

Determine if the patient is qualified for the sample▪ If the patient is deceased, in hospice, moved out of the country or did not have Fee-for-Service (FFS) Medicare as their primary payer select "Not Qualified for Sample", select the applicable reason from the provided drop-down menu, and enter the date the patient became ineligible.

Please note, this guidance would be the same for all measures in the 2019 CMS Web Interface.

Frequently Asked Measure Questions

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MeasureID

Question Answer

PREV-13 For the denominator 2 population, some patients have the E78.00 pure hypercholesterolemia documented and others have the E78.00 hypercholesterolemia. If a patient has the code E78.00 hypercholesterolemia listed, but it does not say "pure or familial," would this count for the denominator?

The measure requires confirmation of pure or familial hypercholesterolemia. Using a combination of written documentation and an applicable code is acceptable, as long as it supports the appropriate diagnosis.

RESOURCES & WHERE TO GO FOR HELPPresenter: Sandra Adams Slaughter, CMS

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Resources

• 2019 QPP Resource Library

- Website: https://qpp.cms.gov/about/resource-library

- 2019 MIPS Quality Performance Category

- 2019 CMS Web Interface Fact Sheet

- 2019 CMS Web Interface Measure Specifications and Supporting Documents

- 2019 CMS Web Interface Sampling Methodology

- 2019 CMS Web Interface & CAHPS for MIPS Survey Assignment Methodology

- 2019 CMS Web Interface Excel Template

- 2019 CMS Web Interface Excel Template with Sample Data

- 2019 CMS Web Interface Data Dictionary

- 2019 CMS Web Interface User Guide

- 2019 CMS Web Interface FAQs

- 2019 CMS Web Interface User Demo Videos (Playlist)

• QPP Help and Support - Website: https://qpp.cms.gov/about/help-and-support

- Materials: Videos, support calls, online courses, learning network, APM learning systems, and developer tools

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Resources

• 2019 QPP Webinar Library

- Website: https://qpp.cms.gov/about/webinars

- 2019 CMS Web Interface User Demonstration (Recorded 11/13/2019)

• Recording, Slides, Transcript

- CMS Web Interface Kick Off Call (Recorded 12/11/2019)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 1 (Recorded 1/15/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 2 (Recorded 01/22/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 3 (Recorded 01/29/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 4 (Recorded 02/05/2020)

• Recording, Slides, Transcript

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Resources

• 2019 QPP Webinar Library (continued)

- Website: https://qpp.cms.gov/about/webinars

- CMS Web Interface Weekly Support Call: Session 5 (Recorded 02/12/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 6 (Recorded 02/19/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 7 (Recorded 02/26/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 8 (Recorded 03/04/2020)

• Recording, Slides, Transcript

- CMS Web Interface Weekly Support Call: Session 9 (Recorded 03/011/2020)

• Recording, Slides, Transcript

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Resources

• Medicare Shared Savings Program ACO:

- Website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html

- Quality Measures & Reporting Standards: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality-Measures-Standards.html

- Weekly ACO Spotlight Newsletter

• Next Generation ACO Model:- Website: https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

- Connect Site: https://app.innovation.cms.gov/NGACOConnect/

- Weekly Newsletter

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Medicare Shared Savings Program and Next Generation ACOs

Get Help from CMS

• Quality Payment Program:

- E-mail: QPP@cms.hhs.gov

- Phone: 1-866-288-8292 (TTY: 1-877-715-6222)

• Medicare Shared Savings Program ACO:

- E-mail: sharedsavingsprogram@cms.hhs.gov

• Next Generation ACO Model:

- E-mail: NextGenerationACOModel@cms.hhs.gov

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Help Us Improve the Quality Payment Program Experience!

We’re looking for participants to collaborate with us and provide feedback regarding the Quality Payment Program website (qpp.cms.gov), including the following:

The QPP Research Teams invite you to participate in our Human-Centered Design efforts.

Interested in participating?Email your name, title, topic of interest, and organization to:

QPPUserResearch@cms.hhs.gov

Our research sessions range from 30-60 minutes and you can join by phone or webinar.

• Educational Materials• Website Content • Website Design

• Reporting Design• Eligibility Content Layout• Performance Feedback Layout

Question and Answer Session

To ask a question over the phone line, please raise your hand and we

will unmute your line.

For those dialed in via phone, you must have your unique audio pin entered. If you’re listening through your

computer speakers and want to ask a question, you must have a working microphone.

You may also submit questions via the Questions tab for speakers to read aloud.

Speakers will address as many questions/comments as time allows.

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Get Help from CMS

• Quality Payment Program:

- E-mail: QPP@cms.hhs.gov

- Phone: 1-866-288-8292 (TTY: 1-877-715-6222)

• Medicare Shared Savings Program ACO:

- E-mail: sharedsavingsprogram@cms.hhs.gov

• Next Generation ACO Model:

- E-mail: NextGenerationACOModel@cms.hhs.gov

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