2019 CMS Web Interface Quality Reporting for MIPS Groups and ACOs

CMS Web Interface Support Call

March 11, 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 7 (Recorded 02/26/2020)

• Recording, Slides, Transcript

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Announcements

• CMS Web Interface Submission Period (January 2, 2020 - March 31, 2020)

- Submission Period

• The submission period for the CMS Web Interface aligns with other submission types, and closes promptly at 8:00pm Eastern Daylight Time (EDT) on Tuesday, March 31, 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 sufficient time to receive assistance from the Quality Payment Program Service Center, have Other CMS Approved Reason requests reviewed by CMS, and complete the CMS Web Interface reporting requirements. 4

CMS Web Interface Key Dates

Announcements

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Upcoming CMS Web Interface Support Calls

• Weekly Support Calls

- Please note: All weekly support calls listed below will be held on Wednesdays from 1:00pm to 2:00pm EDT.

• For more information on the support calls and links to register, review the 2019 CMS Web Interface Support Calls flyer.

• If you encounter any registration issues or audio issues during a support call, please send an e-mail to CMSQualityTeam@Ketchum.com.

March 18, 2020

March 25, 2020

Reminders

• Other CMS Approved Reason skip requests must be submitted through the CMS Web Interface. - A CMS Approved Reason is a way to skip a patient attributed to a measure during

Denominator Confirmation.

• Reserved for circumstances that are unique, unusual, and not covered by any of the denominator exclusions or denominator exceptions identified in the measure specifications.

• Patients for whom a 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.

• Please review the 2019 measure specifications thoroughly before submitting a CMS Approved Reason request

• Submitting a “2019 CMS Approved Reason” after Friday, March 20, 2020 may cause your request not to be processed prior to the close of submission. Submit such requests 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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MEDICAL RECORD DOCUMENTATIONPresenter: Aruna Jhasti, CMS

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Medical Record Documentation

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No. Question Answer

1 Are we allowed to go outside of the ACO participants to find medical record data?

Yes. CMS encourages ACOs to obtain medical records for their assigned and sampled patients. This includes collaborating with physicians and/or other clinic staff both inside and outside the ACO (including but not limited to the NPIs provided in the CMS Web Interface), as well as facilities both inside and outside the ACO, with such collaboration attempts being repeated throughout the course of the data collection period, if needed. Note that the data entered into the CMS Web Interface should never reflect services provided after the end of the performance year (i.e., after 12/31/2019).

Medical Record Documentation

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No. Question Answer

2 Can a MIPS group add documentation to the EMR in 2020 for PY2019? For instance, if a colonoscopy is not found in the EMR during the data collection period for PY2019 and staff reach out to a performing facility to get a copy and it is scanned in EMR in 2020, can that be counted for PY2019?

The QPP measures should be completed based on information that is available in the medical record prior to the end of the measurement period. There could be instances where the procedure/encounter occurred toward the end of the measurement year and the medical record was updated early in 2020, but these instances should not be the norm. It would be more beneficial to the patient if coordination of care coincided with the patients’ encounters as opposed to collecting missing information afterwards for purposes of quality reporting.

The submission period is not intended to be a time for filling in missing information which was only identified due to the patient being attributed to a measure(s) for performance purposes. The measures are not intended to interfere with clinical practices. If a measure calls for information that is not available, then the provider may not meet the intent of the measure.

FREQUENTLY ASKED MEASURE QUESTIONS

Presenter: Angie Stevenson, CMS Contractor

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HTN-2 Controlling High Blood Pressure

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No. Question Answer

1 HTN-2: What should be reported if the most recent blood pressure value is documented incorrectly (i.e., 18/72)?

In the event the most recent blood pressure value is documented incorrectly, move to the next most recent valid blood pressure documented within the medical record.

2 Do we include blood pressures taken from Urgent Care?

Yes. Urgent Care is an outpatient setting. The HTN Coding document contains Urgent Care denominator codes.

3 "Are blood pressure readings from an Inpatient setting or emergency department acceptable?

Yes. Although the measure is intended to be outpatient, blood pressure readings from any clinical setting are acceptable when reporting the numerator. It would be appropriate to move to the next most-recent blood pressure if the most recent blood pressure from an inpatient setting or ED is not within normal parameters.

HTN-2 Controlling High Blood Pressure

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No. Question Answer

4 If the patient has a visit during the measurement year with a billing code of I10 for essential hypertension would this count for confirming the diagnosis?

No. Coding alone is not sufficient documentation to confirm the diagnosis. There must be medical record documentation to support that the patient has "essential" hypertension.

5 If there is medical record documentation of essential hypertension during the year prior to the measurement period, but the diagnosis is not found during the measurement period, can we confirm the diagnosis?

For denominator confirmation, the diagnosis cannot end prior to the start of the measurement period. Medical record documentation should support that the patient has a documented diagnosis of essential HTN within the first six months of the measurement period OR any time prior to the measurement period but does not end before the start of the measurement period select.

RESOURCES & WHERE TO GO FOR HELPPresenter: Aruna Jhasti, 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

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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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