The Essential Emergency Medicine Guide to the MIPS 2018 Final Rule

The Essential Emergency Medicine Guide To The MIPS 2018 Final Rule

MIPS Year 1

The 2017 MIPs transition year afforded the relatively efficient and effective capture and reporting via Medicare claims of a limited number of applicable Emergency Medicine (EM) quality measures. This was done in order to achieve the minimum 3-point threshold for a MIPS Total score to avoid -4% penalties effective in the 2019 payment year. However, due to very limited EM Specialty applicable measures, it was extremely unlikely for any providers reporting for the Quality Payment Program (QPP) via claims in 2017 to qualify for any upward adjustment (bonus) in payments; final results are not yet available until later in 2018.

MIPS Year 2

The transition period is now over and it is a very different picture for reporting in 2018. Since congress’ removal of the Sustainable Growth Rate method to define Medicare payments, an environment in which CMS attempts to contain costs and improve quality, remain very confusing and information is unclear, even to emergency medicine experts. Furthermore, CMS is ineffective in clarifying their own confusing rules.

We will compare the requirements between 2017 and 2018, explore the advantages of Registry Reporting vs. Claims Based Reporting and identify Improvement Activities which may apply to Emergency Medicine.

Low Volume Exclusion Threshold:

The CMS Final Rule was issued on November 1st 2017, and the 2018 program is much more involved. One of the noted improvements includes a higher minimum threshold for MIPS Total score and limited and complex applicable quality measures for ED specialty. Furthermore, it places more burden on providers to perform and to be more actively involved than ever before.

For MIPS optimal scoring in CY 2018, providers will need to report 6 quality measures with data completion and meet case minimums (20), and 4 Clinical Practice Improvement Activity (CPIA) measures. Reporting periods are a full 12 months for Quality and 90 days for CPIA. The minimum total threshold score to avoid a penalty increases from 3 Total MIPS points in 2017 to 15 points in 2018. CMS uses Measure Achievement points to calculate the Quality Performance Category score for each applicable category:

The Essential Emergency Medicine Guide To The MIPS 2018 Final Rule

This has increased to $90,000 in allowable Medicare charges, or 200 Medicare patients per year. On the plus side, this means that more low volume providers will be excluded from reporting and thus avoid penalties, which is good news for part-time providers, MLPs, fast track providers etc. but conversely reduces the number of providers with potential to earn an upward adjustment, if that would be feasible. Avoiding the penalty is obviously the primary goal.

Claim-based reporting does remain an option for Quality measures, but it must be stressed that it is not without issues, costs or risks. The challenge for claims-based reporting in 2018 is in avoidance of a penalty. The opportunity for any upward adjustment is questionable at best because there are not 6 EM applicable or viable measures available to successfully report or which might meet the minimum case size requirement (20 cases). Attaining the required 60% data completeness on measures is not an issue due to special custom programming DS has in place to capture and report a measure. Each successfully reported quality measure (at least 20 cases with 60% data completeness) can score up to 10 measure achievement points each. However, if case minimum is not met the score will only be 3 measure achievement points per measure. Note: Measure Achievement Points are used to calculate a Quality Performance Category score.

Our interpretation is that relying on claims-based Quality reporting alone for 2018 reporting will not afford any possibility of upward adjustment for ED providers. Furthermore, we cannot offer assurance that reporting on the minimal number of relevant quality measures. We believe that it’s possible to get 3 measure achievement points via claims-based reporting with a case count of <20, but definitely NOT possible to get MORE than 3 measure achievement points unless the case count is greater than 20, the measure has a benchmark, and the provider’s performance is sufficiently high.

Therefore, based on our understanding of the scoring system, we believe that if providers elect and perform as described below to score the MIPS Total Score threshold of 15 points, a 5% penalty may be avoided on 2020 payments and, in some cases, there may be a slight potential for an upward adjustment:

1. Providers select, perform and attest to 2 High Value Clinical Practice Improvement Activities (IA) from the 16 activities that we have identified as possible options for EM practices on page 6. The Group may attest on behalf of all providers to achieve 40 measure achievement points for a category that carries a 15% weight in the overall score. Note: 40 IA category achievement points adds 15 points to the MIPS Total score and avoids a negative adjustment in payment year 2020, even if NO quality measures are submitted.

40/40=1 x .15 x 100= 15 Total MIPS Points

Caveat: Attesting to IA as a Group performance means that ZERO Quality measures can be reported via claims for individual providers.


2. Each individual provider selects, performs and later attests to 2 High Value IA from the list of possible options on page 6.

Note: Providers, and not the billing organization are required to perform and then attest to these IA themselves.

Additional Quality reporting for further measure achievement points and a potential upward adjustment if #2 above is selected;

1. Quality measure from the ED specialty measures; #415 CT for blunt        head trauma in patients >18 years.

Note: High Value measure reported on the Medicare claim

With the reduced choices in applicable measures and other restrictions, the writing is clearly on the wall that claims reporting will eventually be discontinued, and groups will need to source alternative mechanisms for reporting, such as via a national registry, ACO, or facility-based reporting (purportedly available for 2019 per 2018 Final Rule).

Advantages of Registry Reporting Vs Claims Base Reporting

The Essential Emergency Medicine Guide To The MIPS 2018 Final Rule

A. More QPP measures are available to report


B. For Qualified Clinical Data Registries (QCDRs), additional non QPP measures are available to report


C. It is FAR easier to meet the 20 case minimum because:

    i.   Case count is per the group as a whole rather than an individual

    ii.  All patients, rather than just Medicare patients are counted


D. Possibility of earning up to 10 measure achievement points per measure, rather than just 3 for claims based reporting


E. Possibility of earning Measure Bonus Points for reporting additional High Priority measures.


F. Possibility of earning bonus points for “Improvement” in subsequent years.


G. Ability to report Improvement Activities as a group rather than each individual having to do so


H. Possibility of reaching a total MIPS score of over 70 and therefore being included in the Exceptional Bonus Pool.

Currently we are aware of 3 registries which could potentially handle MIPS quality reporting:

1. ACEP CEDR      2. Covisint     3. E-CPR

Because of the relativity to EM, for several months DuvaSawko has been researching ACEP’s Clinical Emergency Data Registry (CEDR) tool and several of our executives met with CEDR administration leaders to learn the specific requirements and potential of this tool as an alternative reporting option for clients. A few DuvaSawko clients are independently pursuing applications for this registry option for 2018.

ACEP’s CEDR is dependent on the ability to connect to a hospital database housing the clinical records for all of the client’s ED patients, and only those patients. It then relies on a combination of custom configured data element mapping, keyword detection, and natural language processing to automatically determine measure performance, non-performance, or denominator exception. They also require the ability to connect to the RCM vendor’s database to determine which cases should be included in which measures based on CPT and ICD codes assigned by the RCM vendor. We have observed CEDR become a more mature product over time, although we do still have some concerns with liability, cost etc. Furthermore, since their success is contingent on hospital cooperation for pulling data from the EMR, that requires collaboration with hospital IT personnel, which can take time and engagement by group leadership.

We do have and will willingly provide any contact information for CEDR to start the engagement process for any interested groups and strongly suggest that clients not reporting via ACOs reach out to CEDR or other registries for more information as soon as possible.

Please reach out to the team at DuvaSawko regarding any questions or guidance your group may have to need your decision for 2018 reporting.

We are here to help support you in navigating these challenging times in a CMS Environment and are devoutly committed to improving quality care outcomes and reducing costs.

Improvement Activities Which May Apply To Emergency Medicine:


The descriptions below are abbreviated. There is a separate CMS document detailing the full description of these, which we will readily provide.

  1. Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care. (High)
  2. Use of telehealth services and analysis of data for quality improvement. (Medium)

  3. Collection of patient experience and satisfaction data on access to care and development of an improvement plan. (Medium)

  4. Provide episodic care management, including management across transitions and referrals. (Medium)

  5. Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group. (Medium)

  6. Timely communication of test results. (Medium)

  7. Establish effective care coordination and active referral management. (Medium)

  8. Establish effective care coordination and active referral management. (Medium)

  9. Develop pathways to neighborhood/ community-based resources to support patient health goals. (Medium)

  10. Collection and follow-up on patient experience and satisfaction data. (High)

  11. Use evidence-based decision aids to support shared decision-making. (Medium)

  12. Regularly assess the patient experience of care through surveys. (Medium)

  13. Provide self-management materials. (Medium)

  14. Participation in Maintenance of Certification Part IV. (Medium)

  15. Seeing new and follow-up Medicaid patients in a timely manner. (High)

  16. Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. (Medium)

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