Part III: MIPS Promoting Interoperability Performance Category in 2020

Editor’s note: This article is the first part of a five-part series on the Centers for Medicare and Medicaid (CMS) Quality Payment Program (QPP) in 2020.

  • Part I provides an update to the current requirements for MIPS, emphasizing key components that changed in 2020.
  • Part II will discuss the current requirements for the MIPS Quality performance categories.
  • Part III will focus on the current requirements for the MIPS Promoting Interoperability performance categories.
  • Part IV will detail the requirements for the cost and improvement activity performance categories of MIPS and MIPS audit considerations.
  • Part V will review the 2020 QPP Alternative Payment Models and MIPS APMs.

By Michael Stearns, MD, CPC, CFPC, CRC

The Centers for Medicare and Medicaid Services (CMS) made relatively few changes to the Promoting Interoperability (PI) category of MIPS. However, the overhaul of this category in 2019 created challenges for some practices that will carry over into 2020.

Reporting Period: The reporting period for PI remains a minimum of 90 consecutive days in 2020. Any 90-day period can be selected, so practices may wish to start collecting PI data well before the last possible performance period start date of October 3, 2020. This approach allows users to identify areas of deficiency prior to the actual reporting period.

Weighting and Reweighting Requirements: PI continues to be weighted at 25 percent of the MIPS total score. However, it is reweighted to 0 percent (and its points are reallocated to the quality category) if one or more of the following criteria are met:

  • Reporting by a non-physician clinician. This includes nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, physical therapists, occupational therapists, qualified audiologists, qualified speech language pathologists, registered dieticians, or registered nutritional professionals.
  • A group of nonphysician clinicians (with no physicians as per the CMS definition of physician). Individual clinicians or groups that claim a PI hardship exception if they meet certain challenges during the performance year, such as the use of decertified electronic health record (EHR) technology, insufficient internet connectivity, or significant financial distress. Hardship exceptions must be submitted by December 31, 2020.

The following circumstances qualified for exceptions in 2019 but may change when the PI hardship exception application process for 2020 opens in mid-year:

  • A small group or individual clinician has experienced significant barriers to meeting the PI category requirements
    The practice is using decertified electronic health record technology
  • The practice is facing extreme and uncontrollable circumstances, including but not limited to: disasters, natural and otherwise
  • Practice closure
  • Severe financial distress
  • Vendor issues
  • Lack of availability of certified EHR technology (CEHRT). This is defined as lack of control over the availability of CEHRT in one or more practice locations where more than 50 percent of the patient encounters occurred.

CMS will generally grant hardship exceptions without requesting supporting information. Practices will be required to provide evidence as to why they qualified for an exception if the practice is selected for a data validation audit.

Non-patient-facing clinicians and groups are also eligible for reweighting of the PI category points to the quality category. These are defined as MIPS-eligible clinicians that bill for fewer than 100 patient-facing encounters during the MIPS determination period. CMS modified the requirement for groups for 2020. For a group to be eligible for reweighting, more than 75 percent of the national provider identifiers (NPIs) in the group must be non-patient-facing.

Hospital-based clinicians, defined as MIPS-eligible clinicians who furnish 75 percent or more of their covered professional services in inpatient hospital (place of service [POS] 21), on campus outpatient hospital (POS 22), off campus outpatient hospital (POS 19), or emergency room (POS 23) settings. CMS modified the group reporting requirement in the 2020 Physician Fee Schedule (PFS) Final Rule. Starting in 2020, more than 75 percent of the clinicians in the group must meet the requirement for being hospital-based as individuals for the group to qualify for reweighting.

Ambulatory surgery-based clinicians are defined as a clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by POS 24.

The above listed clinicians and groups retain the option to submit PI data. If they report PI data, they will be scored the same as other groups submitting PI data. If they elect not to report PI data, 25 percent weighting of the PI category will be redistributed to the quality performance category (in most cases).

PI Objectives and Measures

The 2020 finalized PI objectives, measures, and point totals are shown in Table 1. All the minimum requirements identified in Table 1 must be met for the entire PI performance category to receive a score greater than zero, unless an exclusion for the measure is claimed.

Table 1: Overview of PI Objectives and Measures
Objectives Measure Minimum Reporting Requirement (If no exclusions claimed) Maximum Points
E-Prescribing E-Prescribing (required) One prescription submitting electronically 10 points
Bonus: Query of Prescription Drug Monitoring Program (PDMP) None: Optional measure 5 bonus points
Health Information Exchange       Support Electronic Referral Loops by Sending Health Information (required) Using CEHRT export and send one summary of care document electronically in association with a referral or transition of care 20 points
Support Electronic Referral Loops by Receiving and Incorporating Health Information (required) Using CEHRT receive and incorporate one summary of care document for patients in transition of care, inbound referrals, or a patient never previously encountered by the clinician 20 points
Provider to Patient Exchange Provide Patients Electronic Access to Their Health Information (required) For at least one unique patient seen during the performance period provide timely access to view online, download, and transmit to a third his or her health information, AND, health information is available to the patient via the application of their choice 40 points
Public Health and Clinical Data Exchange

(Maximum of 10 points under this objective)

Immunization Registry Reporting Active engagement with a public health agency to receive and submit immunization data 5 points
Electronic Case Reporting Active engagement with a public health agency to electronically submit case reporting of reportable conditions 5 points
Public Health Registry Reporting Active engagement with a public health agency to submit data to public health registries 5 points
Clinical Data Registry Reporting Active engagement with a clinical data registry to submit data 5 points
Syndromic Surveillance Reporting Active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting 5 points
ePrescribing Objective

The requirements for the e-prescribing measure in this objective have not changed from 2019. Clinicians need to create at least one permissible prescription that includes querying of a drug formulary and transmission of the prescription electronically using CEHRT. The score for this measure is determined by the percentage of prescriptions created that meet these criteria. All prescriptions, including handwritten prescriptions, attributed to the clinician’s NPI are included in the denominator.

Clinicians or groups who write fewer than 100 permissible prescriptions during the performance period can claim an exclusion for this measure. If this exclusion is claimed, the 10 points assigned to this measure will be redistributed to the Provide Patients Electronic Access to Their Health Information PI measure.

Clinicians and groups that work in multiple settings of care, often using disparate EHRs and e-prescribing applications, are required to aggregate the total number of prescriptions written by the practice. CMS requires practices to aggregate data on all prescriptions created by the individual or group regardless of method used (e.g., electronic, phone order, paper, etc.) to populate the denominator for this measure. They must also identify the prescriptions that meet the e-prescribing requirements, as these are used to populate the numerator for this measure.

Practices that see 50 percent or more of their patient encounters in settings of care where they have no control over the use of CEHRT may be eligible to claim a hardship exception for the PI category in 2020. However, the recommended best practice would be to work towards harmonizing the e-prescribing process by writing all prescriptions using a single e-prescribing tool.

Opioid Measures

Two optional measures were introduced under the e-Prescribing Objective for 2019:

  • Query of Prescription Drug Monitoring Program (PDMP)
  • Verify Opioid Treatment Agreement

CMS removed the Verify Opioid Treatment Agreement optional measure for the 2020 performance period.

This Query of PDMP measure remains optional and if utilized will earn practices five bonus points in the PI category. The reporting requirement for the Query of PDMP measure has been changed from having to report performance data (i.e., numerator/denominator values) to a simple “Yes” or “No” attestation in 2020 (and retroactively to the 2019 performance year).

CMS stated in the 2020 PFS Final Rule: “A ‘yes’ response would indicate that for at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS-eligible clinician then used data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law.”

Table 2. CCDA Contents
Information Type
Patient name
Demographic information (preferred language, sex, race, ethnicity, date of birth)
Smoking status
Current problem list (eligible clinicians may also include historical problems at their discretion)*
Current medication list*
Current medication allergy list*
Laboratory test(s)
Laboratory value(s)/result(s)
Vital signs (height, weight, blood pressure, BMI)
Procedures
Care team member(s) (including the primary care provider of record and any additional known care team members beyond the referring or transitioning clinician and the receiving clinician)
Immunizations
Unique device identifier(s) for a patient’s implantable device(s)
Care plan, including goals, health concerns, and assessment and plan of treatment
Referring or transitioning clinician’s name and office contact information
Encounter diagnosis
Functional status, including activities of daily living, cognitive and disability status
Reason for referral
*cannot be left blank
Health Information Exchange Objective

There are two measures under this objective. They created challenges for a significant number of practices in 2019 and one of these measures has become more challenging in 2020.

Support Electronic Referral Loops by Sending Health Information Measure: This measure requires clinicians to create and then export at least one Summary of Care Record using 2015 Ed. CEHRT (in the consolidated clinical document architecture [CCDA] format) when patients are transferred to another care setting or when they are referred to another clinician. Clinicians must have “reasonable certainty” that the receiving clinician is able to receive the CCDA document using an EHR that is capable of importing the CCDA document (although the receiving EHR does not have to be 2015 Ed. CEHRT). CMS clarified that referrals include when a patient is instructed to follow up with a provider they have previously encountered.

Each referral or transition of care that occurs during the performance period is used to populate the denominator. The numerator is populated when the CCDA is created, exported, and exchanged electronically. There is no requirement for the receiving clinician to import or otherwise address the inbound CCDA document. However, the exchange must be compliant with security protocols for ePHI under HIPAA. Examples of acceptable transmission methods include secure email, Health Information Service Provider (HISP), query-based exchange, or use of third-party HIE.

The CCDA must contain the fields listed in Table 2, above, if the MIPS-eligible clinician knows it. The current problem list, medication list, and allergy list fields cannot be blank. For example, if the patient is not taking medication, the field should contain text such as “patient on no current medications.” Other fields may be left blank if the information is not available.

This measure has an exclusion for clinicians and groups that transfer patients to another setting or refers a patient fewer than 100 times during the performance period. Referrals are defined in the specification document for this measure as: “Cases where one provider refers a patient to another, but the referring provider maintains his or her care of the patient as well.”

If the exclusion is claimed the 20 points from this measure are redistributed to the Provide Patients Electronic Access to Their Health Information measure, giving it a weighting of 60 points.

Some practices have experienced challenges with identifying settings of care and clinicians that have the capability (and willingness) to receive inbound electronic summary of care records. CMS stated in the 2020 PFS Final Rule that if the practice cannot identify at least one clinician or facility capable of receiving and incorporating the summary of care document, the practice will receive a total PI score of zero points.

Performance on this measure will continue to be challenging in many settings. Each referral, based on the definition and information provided above, and each transition of care must be tracked and used to populate the numerator and denominator for this measure.

CMS provides the option of including or excluding all referrals and transitions of care for providers sharing the same EHR. CMS clarified that this includes internal referrals and transitions of care under the same tax identification number (TIN). However, the referring provider must create the CCDA using CEHRT and send it electronically to the receiving clinician/facility. This may be an option for practices that are facing challenges with meeting the minimum requirement for this measure. In settings where there are no providers or facilities capable of receiving the CCDA document, practices may elect to include internal referrals when applicable. This would allow practices to avoid a score of zero points for the PI performance category.

Support Electronic Referral Loops by Receiving and Incorporating Health Information Measure: This measure requires clinicians to import and reconcile at least one CCDA document under the following circumstances:

  • The practice is using 2015-edition CEHRT
  • A CCDA has been received by the practice
  • One of the following criteria are also met:
    • The clinician was the receiving party of a transition of care or referral
    • The clinician has never before encountered the patient

Only encounters that meet these requirements are counted in the denominator. If the receiving clinician/facility does not “receive” a CCDA, the encounter is excluded from the denominator. CMS did not further specify the meaning of “received,” but in general this implies that a clinician or facility sent the CCDA to the receiving provider.

Practices are required to import the CCDA and then reconcile at a minimum the following CCDA fields: current problem list, current medications, and current allergies. Nonmedical staff may perform the reconciliation process under the supervision of a clinician if the clinician or other credentialed medical staff are responsible and accountable for review of the information.

CMS clarified that the term “never before encountered the patient” is not the same as the new patient definition for ambulatory evaluation and management coding, which defines new patients as those not seen by the practice within the past three years. For this PI measure, a patient being seen by a clinician that they have never previously encountered, even if they were seen recently by another clinician in the same group, would be counted in the denominator.

This measure has an exclusion for clinicians and groups that receive transitions of care, referrals, or have patient encounters in which the MIPS-eligible clinician has never before encountered the patient fewer than 100 times during the performance period. These requirements summate; for example, if the practice has 40 inbound referrals, receives 20 patients in transition of care, and 50 encounters where the clinician has never previously encountered the patient, they will not qualify for the exclusion. If the exclusion is claimed, the 20 points for this measure is reweighted to the Support Electronic Referral Loops by Sending Health Information measure.

Some practices may not receive any inbound CCDAs during the performance period. CMS granted an exclusion for the 2019 reporting year for when practices were unable to implement this measure. It required no specific documentation and addresses this specific scenario. For the 2020 reporting year this exclusion has been removed. Practices that do not receive, import, and reconcile at least one CCDA during a transition of care, inbound referral, or newly encountered patient will receive a zero in the numerator for this measure and receive a total PI score of zero out of 25 points.

CMS allows clinicians the option of counting referrals/transition of care when the same EHR is being used by the sending and receiving parties, including internal (same TIN) referrals as the denominator. However, the receiving clinician must go through the steps of receiving, importing, and reconciling the CCDA for the encounter to count in the numerator. The practice must also include all internal (and external) inbound referrals, transitions of care, and new patient encounters in the denominator.

Practices that have no inbound CCDAs from external sources may wish to exercise the internal referral option. In that setting the practice would have greater control over performance on this measure, and higher scores could readily be achieved.

PI measures do not have case minimums or benchmarks. For example, if a practice only received one CCDA from an external referral source that was imported and reconciled, they would receive a numerator/denominator score of 1/1 (e.g., 100 percent performance). This would earn the 20-point maximum score for this measure.

Provider to Patient Exchange Objective

The Provide Patients Electronic Access to Their Health Information Measure has a maximum value of 40 points. It requires that at a minimum of one patient that has an encounter during the reporting period is offered “timely access” to a patient portal or other application they can use to view, download, or transmit their health information electronically. Patients that decline access are still counted in the numerator and denominator for this measure.

The denominator for this measure includes all unique patients seen by the MIPS-eligible clinician during the performance period. The numerator consists of the number of patients seen during the reporting period who were provided or offered timely access to their health information. Timely access is defined as within four business days. This must be ongoing during the reporting period and not limited to information shared in association with encounters.

The measure also requires that clinicians provide the patient with access to their health information via an application of their choosing, as long as the application is compatible with the application programming interface (API) available within the clinician’s EHR. Clinicians may not prohibit patients from using any application, including third-party applications, which meet the technical specifications of the EHR’s API. CMS expects clinicians to provide patients with detailed instructions on how to authenticate their access through the API. Practices covered by civil rights laws are required to provide individuals with disabilities equal access to information and appropriate auxiliary aids and services as provided in the applicable statutes and regulations.

There are no exclusions for this measure. At a minimum the patient will need to be able to view, download, and transmit the following electronic information outlined in Table 3.

Table 3.  Information That Must Be Available to Patients to View, Download, and Transmit
Information Type
Patient name
Provider’s name and office contact information
Current and past problem list
Encounter diagnosis
Procedures
Laboratory test results
Current medication list and medication history
Current medication allergy list and medication allergy history
Vital signs (height, weight, blood pressure, BMI, growth charts)
Smoking status
Immunizations
Functional status, including activities of daily living, cognitive and disability status
Unique device identifier(s) for a patient’s implantable device(s)
Demographic information (preferred language, sex, race, ethnicity, date of birth)
Care plan field(s), including goals, health concerns, assessment, plan of treatment and instructions
Any known care team members including the primary care provider (PCP) of record
Public Health and Clinical Data Exchange Objective

This objective has five measures with similar requirements:

  • Clinical Data Registry Reporting
  • Immunization Registry Reporting
  • Electronic Case Reporting
  • Public Health Registry Reporting
  • Syndromic Surveillance Reporting

Reporting for these measures requires a simple “yes” or “no” attestation as to whether the practice was in (or tracking towards) “active engagement” with a registry/public health agency. If the practice can attest “yes” to two measures or “yes” to one measure and claims an exclusion for any one of the remaining four measures, they will earn the full ten points associated with this objective. If the practice can claim exclusions for two of the measures in this objective, the points in this objective will be reassigned to the Provide Patients Electronic Access to Their Health Information measure.

The active engagement requirements have the same definitions and requirements for all five measures under this objective: The clinician “…is in the process of moving towards sending ‘production data’ to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR).” Practices do not need to re-register each year with a PHA or CDR once they achieve active engagement.

CMS states that active engagement may be demonstrated in one of the following three ways:

  • Option 1—Completed Registration to Submit Data: The practice has completed registration to submit data with the public health agency or clinical data registry to which they intend to submit data. Registration must be completed within 60 days after the start of the MIPS performance period chosen by the practice. The practice must also be “awaiting an invitation” from the PHA or CDR to begin testing and validation. This option is applicable to when the PHA/CDR does not have adequate resources to initiate the testing and validation process.
  • Option 2—Testing and Validation: The practice is in the process of testing and validation of the electronic submission of data. The clinician or group representative must respond to requests from the PHA or CDR within 30 days. Failure to respond twice within the MIPS performance period would result in that MIPS-eligible clinician not meeting the measure.
  • Option 3—Production: The practice, having completed the testing and validation of the electronic submission, is electronically submitting production data to the PHA/CDR.

Each of the five public health/clinical data exchange measures have certain exclusion criteria in common, including:

  • The PHA/CDR operates in a “jurisdiction” where there are no PHAs or CDRs (depending on the measure) capable of accepting electronic PHA/CDR electronic transactions at the start of the performance period.
  • The PHA/CDR operates in a “jurisdiction” where no eligible PHA or CDR (depending on the measure) has declared readiness to receive electronic PHA/CDR transactions as of 6 months prior to the start of the performance period.

Each of the five measures also has a unique exclusion criterion (as shown in Table 4).

Per CMS, “The definition of jurisdiction is general, and the scope may be local, state, regional or at the national level. The definition will be dependent on the type of registry to which the provider is reporting. A registry that is ‘‘borderless’’ would be considered a registry at the national level and would be included for purposes of this measure.” Practices that claim an exclusion for one or more of the above PHA/CDRs will need to carefully review the exclusion criteria and provide supporting documentation if they are selected for a MIPS Data Validation Audit.

Table 4. Exclusion Criteria Unique to Each Public Health and Clinical Data Exchange Measure
Measure Name Exclusion Criteria for Clinician or Practice
Clinical Data Registry (CDR) Reporting The practice does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the performance period.
Syndromic Surveillance Reporting The practice is not in a category of healthcare providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system.
Immunization Registry Reporting The practice does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the performance period.
Public Health Registry Reporting The practice does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician’s jurisdiction during the performance period.
Electronic Case Reporting The practice does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the performance period.
MIPS PI Performance Category: Clinical Documentation Integrity and Audits

Practices should consider creating an audit checklist for the PI performance category supported by documentation. If a data validation audit finds that the practice failed to meet the minimum reporting requirements for any of the required measures, the practice may have their PI score reduced to zero points and could face additional consequences. CMS will in general accept the data and attestations submitted by practices without additional validation during the reporting process. Compliance reviews are limited, at least initially, to the MIPS Data Validation Audit process.

Supporting documentation, including screenshots of actions taken, website information (e.g., for PHA/CDRs), attempts to harmonize data, etc. are strongly encouraged and should be generated during the performance period. CMS requires that practices retain documentation to support all measure submissions for the PI category.

Auditors may request documentation for each performance year, with a look-back period of six years. Screenshots should include information such as date accessed, website addresses, etc. as applicable. This has created an additional information management requirement for the MIPS program.

Caution is advised for the following aspects of PI in particular:

  • Data aggregation across disparate settings of care (if applicable) for all PI measures
  • Meeting the detailed requirements of the HIE Objective measures
  • Ensuring that new information is updated in the patient-facing application within four business days
  • Meeting the specific requirements for claiming exclusions for PI measures
  • Meeting the specific requirements for claiming a hardship exception
  • How documentation supporting actions related to PI is generated, stored, and maintained for a minimum of six years
References

The Centers for Medicare and Medicaid Services (CMS). “2020 Physician Fee Schedule Final Rule.” Federal Register, November 15, 2019. https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other.

CMS. Quality Payment Program Resource Library. https://qpp.cms.gov/about/resource-library.

CMS. Quality Payment Program 2019 Promoting Interoperability Hardship Exception application. https://qpp.cms.gov.

 

Michael Stearns (michael@apollohit.com), is the founder and CEO of Apollo HIT, LLC.

Continuing Education Quiz

Review quiz questions and take the quiz based on this article, available online.

  • Quiz ID: Q2029103
  • Expiration Date: March 1, 2021
  • HIM Domain Area: External Forces
Impact Area

Connection: Facilitating optimal sharing of data between providers, consumers, health information networks, and health plans through technology-enabled, secure access to electronic health information

 

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