Did you know that Medicare is requiring a minimum of 75 MIPS Performance points for the 2022 Performance Period to avoid a negative payment penalty in 2024? 

Introducing the OfficeEMR MIPS Assist 2022 Program

It is becoming increasingly harder to avoid a negative payment penalty for the eligible clinicians required to participate in the Merit Based Incentive Program. That is why we are so excited to formally announce the launch of our OfficeEMR MIPS Assist 2022 program. Let our MIPS Consultants work one-on-one with your team to ensure you meet your MIPS score goal for the 2022 reporting period.

Our comprehensive, user-friendly products and knowledgeable MIPS consultants will guide you to quality reporting success. We will help you:

• Create a plan to avoid a payment penalty in 2024.
• Optimize incentive and potential bonuses.
• Select the right measures and configure OfficeEMR for maximum reporting efficacy.
• Analyze and improve performance.
• Successfully submit data to Medicare.

What's Included

• Formal Consultation with our MIPS Assist Consultant to select the appropriate measures, improvement activities and promoting interoperability measures for your practice to meet your MIPS goals.
• 1-Hour of Template Setup and Customization.
• Training on how to collect, view and report your MIPS Data.
• Quarterly check-ins with your MIPS Consultant to ensure you're score is on track to meet or exceed your goal.
• Assistance with your final MIPS submission to CMS using our partner Mingle Health

Our goal is to help take the guess work out of MIPS reporting for your practice. Through our MIPS Assist program, we will assist your practice in maximizing the amount of points a provider or group practice can earn during the reporting period. 

Am I Eligible for MIPS in 2022?

You can check your eligibility by going to the QPP website and entering your NPI in the Check Your Participation Status section of the screen.

How Much Does It Cost?

The MIPS Assist base package is $1500. This includes MIPS consultation services for up to 3 NPI's. Each additional NPI (above 3) is $125 per provider. Only reporting clinicians should be included in this package.

How Do I Sign-up?

If you are interested in the MIPS Assist Program, you can sign-up here. 

Follow these Steps to Verify Your Eligible Clinician Participation Status:

1. Navigate to the Setup Portal.
   
   
2. Select Providers under Basic Setup.
   
   
3. Search for each billing NPI at the Practice under the Provider Search.
   
   
4. Select the Click here to view MIPS status link.
   
   
5. This will open the CMS QPP Participation Status for the Selected Clinician. Document whether the clinician is eligible as an individual and/or group provider.
6. Go back to step 3 and repeat for all clinicians at the practice.

Check out qpp.cms.gov for more information about how MIPS eligibility is determined. 

CMS has opened the 2022 extreme and uncontrollable circumstances exception application and MIPS Promoting Interoperability Performance category hardship Exception application to allow clinicians, groups, virtual groups and APM Entities to submit an application requesting MIPS performance category reweighting due to the current COVID-19 public health emergency. 

Follow these steps to apply for the COVID-19 related extreme and uncontrollable circumstances exception for a group, virtual group or APM Entity: 

1. Log in to qpp.cms.gov.
2. Click on the Exceptions Application menu option.
   
3. Select Add New QPP Exception.
   
4. Pick the Extreme and Uncontrollable Circumstances Exception option.
   
5. Set the Application Type to the appropriate option for your practice.
   
6. Complete the Practice Information. For the Submitter/Third Party Intermediary Relationship - click what applies. Most of the time this is set to Physician Staff.
   
7. Select the appropriate Uncontrollable Circumstances Event Type (COVID-19) and set your Event Date Range.
   
8. Choose the Performance Category Affected options you wish to apply for an exception for. If you want the hardship to apply to the entire MIPS program, you will select all categories.
   
9. Submit your application. Make sure to print a copy of the application showing that it was accepted for your records.

References: 

https://qpp.cms.gov/mips/exception-applications?py=2022

Practices with more than 1 eligible clinician will need to determine whether they wish to report as individuals or as a group.

• An individual clinician submits measures and activities for the practice(s) (identified by TIN) in which the clinician is MIPS eligible.
• A group is defined as a TIN with 2 or more eligible clinicians, including at least 1 MIPS eligible clinician, as identified by their NPIs who have reassigned their Medicare billing rights to the TIN.
• Most practices with 2 or more eligible clinicians will report as a group in order to earn incentives for and to protect the TIN against negative payment adjustments.
• Learn more about the Quality Payment Program in CMS’s 2020 MIPS Quick Start Guide.

In order to calculate and extract MIPS Quality and Promoting Interoperability data, practices need to setup each MIPS eligible clinician on the MIPS dashboard following these steps:

1. Navigate to the Reports Portal.
   
   
    
2. Select MIPS Dashboard under the Meaningful Use section.
   
   
    
3. Click on the New button to add a new provider.
   
    
4. Setup the provider reporting period using the Edit Provider screen.
   
    
5. Press the Save button.
6. Repeat the process for all MIPS Eligible Clinicians.

Follow these steps to edit a provider setup on the MIPS Dashboard:

1. Select the Clinician in the list of Providers on the left.
    
2. Click on the Edit button.
   
   
3. Edit the Clinician as necessary and press the Save button.
   
   

Follow these steps to remove a clinician from the MIPS Dashboard:

1. Select the Clinician in the list of Providers on the left.
   
   


2. Click on the X icon to delete the Clinician.
   
   

For the 2022 MIPS reporting period, the Quality performance category is worth 30% of the Clinician's/Group's final score, this is down from 40% points in 2021. This percentage can change due to Exception Applications or Alternative Payment Model (APM) Entity participation. Participants are required to collect quality measure data for the 12-month performance period (January 1-December 31, 2022). 

General reporting requirements:

• You'll typically need to submit collected data for at least 6 measures (including 1 outcome measure or high-priority measure in the absence of an applicable outcome measure), or a complete specialty measure set.
• You'll need to report performance data for at least 70% of the patients who qualify for each measure (data completeness).
• You can submit measures from different collection types (except CMS Web Interface measures) to fulfill the requirement to report a minimum of 6 quality measures.

iSalus Healthcare has partnered with with 2 companies for MIPS Quality Reporting in 2022. Those partners are Mingle Health and Dynamic Health IT.

• Mingle Health is an industry-leading Medicare Qualified Clinical Data Registry. They offer robust quality reporting options for our practices and complete MIPS (Promoting Interoperability, Improvement Activity and Quality) reporting to CMS. Click here to get started with Mingle Health.
• iSalus has also integrated with Dynamic Health IT's CQMsolution as our Electronic Clinical Quality Measure (eCQMs) quality reporting tool. We currently support the following eCQMs through our integration with CQMsolution:
  • CMS22v10 / MIPS Quality ID 317 - Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented
  • CMS68v11 / MIPS Quality ID 130 - Documentation of Current Medications in the Medical Record
  • CMS69v10 / MIPS Quality ID 128 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
  • CMS122v10 / MIPS Quality ID 1 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
  • CMS127v10 / MIPS Quality ID 111 - Preventive Care and Screening: Pneumococcal Vaccination Status for Older Adults
  • CMS138v10 / MIPS Quality ID 226 - Preventive Care and Screening: Tobacco Use Screening and Cessation Intervention
  • CMS147v11 / MIPS Quality ID 110 - Preventive Care and Screening: Influenza Immunization
  • CMS156v10 / MIPS Quality ID 238 - Use of High-Risk Medications in the Elderly
  • CMS165v10 / MIPS Quality ID 236 - Controlling High Blood Pressure

Most eligible MIPS clinicians will partner with Mingle Health or another registry as registries have access to hundreds of quality measures for practices to report on vs. the 9 available eCQMs currently supported by iSalus. To sign-up for Mingle Health, purchase a MIPS Solutions package for each reporting clinician here. Be sure to utilize the ISALUS21 coupon code to receive our discounted rate of $588/Clinician. 

For more information on reporting your 2020 Quality data using our CQMsolution eCQMs, contact our support staff at support@isalushealthcare.com. Learn more about the Quality Performance Category on the qpp.cms.gov website.

iSalus Healthcare offers 4 different quality data extract files which are exported and uploaded into the Mingle Health site to calculate practice MIPS Quality reports. They are as follows:

MIPS Quality PM File Contents

All practices must extract and provide this file to Mingle Health for quality measure calculation. It includes:

• Claim information for patients seen for the NPI and TIN during 01/01/Reporting Year – 12/31/Reporting Year

MIPS Quality Interventions File Contents

Practices tracking quality data with clinical data will need to extract this file if their quality measures include the following clinical data:

• Immunizations setup with a CVX Code
• Patient Education Materials selected in the Patient Education chart tab
• Procedure type Orders
• Referral type Orders
• Lab, Radiology and Pathology type Orders
• Template items setup as CCDA Care Plan Goals or Care Plan Instructions

MIPS Quality Medications File Contents

Practices tracking quality data with clinical data will need to extract this file if their quality measures include the following clinical data:

• Medications for patients seen during the reporting period
• Medications Documented Indicator (Medications Marked as Reviewed on the Patient Timeline Summary)

MIPS Quality Observations File Contents

Practices tracking quality data with clinical data will need to extract this file if their quality measures include the following clinical data:

• Vitals including BMI, Diastolic BP, Systolic BP, Height, Weight, Pain Scale, Heart Rate
• Order Results
• Problems where the status is not Removed
• Allergies
• Smoking Status – Pulls a Specific Global Entity from the Patient History template

Practices who have engaged with our Clinical Data Registry Mingle Health for their quality reporting will need to properly setup and extract data files from the MIPS Dashboard to upload into the Mingle Health portal. The MIPS Dashboard has 4 file extracts that are used for quality reporting depending upon how a practice is tracking their quality measures. Click here to learn more about the specific contents of the Quality Data Extract files. 

Follow these steps to setup the Practice's Mingle Client ID and the time frame in which to pull the MIPS quality data extract files:

1. Click on the Gear button.
   
   


2. Enter the practice Mingle Client ID and setup the appropriate time frame to pull clinical data for the clinical Interventions, Medications and Observations.
   
   


3. Press the Save button to save the settings.

When practices are ready to obtain an updated quality report from Mingle Health, they will need to extract the quality data files to upload in the Mingle Health portal. 

Follow these steps to extract the MIPS Quality Data files:

1. Click on the Individual Clinician or Group to extract files for.
   
   


2. Click on the Quality download menu.
   
   


3. Select All Providers.
   
   


4. Click on the Download Cloud button for all of the files necessary to calculate your practice’s quality measures.These will download to your C drive – iSalusExport folder on your computer’s hard drive.
   
   


5. Login to the Mingle Health Portal.
   
   


6. Select the Modules menu.
   
   


7. Click on the File Upload menu option.
   
   


8. Set the File Type to Practice Management Data (for the PM file) or Clinical Data Extract (for the Medications, Observations and Interventions files).
   
   


9. Set the File Subtype to Year to Date Data.
   
   


10. Select the or click here button to upload your file. It will be in the C:iSalus Export folder.
    
    


11. Enter the File Description as "Practice Name PM/Medication/Observations/Interventions File".
    
    


12. Press the Upload File & Data button. Repeat until all files have been uploaded to Mingle Health.
    
    

For the 2022 MIPS reporting period, the Improvement Activities performance category is worth 15% of the Clinician's/Group's final score. To earn full credit in this performance category, you must generally submit one of the following combinations of activities: 

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

High-weighted activities receive 20 points and medium-weighted activities receive 10 points. You'll receive double points for each high- or medium-weighted activity you submit if you're an individual clinician, group, virtual group, or APM Entity who holds a qualifying special status. You can check for any special status by singing in to qpp.cms.gov. Small status designation for APM Entities will be displaying in mid-2022. 

Improvement activities have a continuous 90-day performance period (during CY 2022) unless otherwise stated in the activity description.

Clinicians can review the list of possible improvement activities within the Improvement Activities section of the MIPS Dashboard.

You can also learn more about MIPS Improvement Activities at qpp.cms.gov.

For the 2022 MIPS reporting period, the Promoting Interoperability performance category is worth 25% of the Clinician's/Group's final score. Participants will submit a single set of Promoting Interoperability Objectives and Measures to align with 2015 Edition CEHRT.

For Performance Year 2022, you're required to use an Electronic Health Record (EHR) that meets the 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of both for participation in this category.

You must provide your EHR's CMS Identification code (iSalus' ID is 0015ES795WE7KVF) along with a "yes" to:

• The Prevention of Information Blocking Attestation,

• The security risk analysis measure, and;

• The SAFER Guides measure.

Participants must submit collected data for certain measures for 90 continuous days or more during 2022. Promoting Interoperability reporting periods for 2022 in the MIPS Dashboard can start as soon as 01/01/2022. The following measures and activities for 2022:

• Prevention of Information Blocking Attestation: I attest to CMS that I - (A) did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (B) Implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: (1) Connected in accordance with applicable law; (2) Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170; (3) Implemented in a manner that allowed for timely access by patients to their electronic health information; and (4) Implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors. (C) Responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor's affiliation or technology vendor.
  • Measure Score: Required to earn a Promoting Interoperability score > 0
  • Clinicians must attest YES to this measure
• Security Risk Analysis: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by CEHRT in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.
  • Measure Score: Required to earn a Promoting Interoperability score > 0
  • Clinicians must attest YES to completing this measure
• SAFER Guides: Conduct an annual self-assessment using the High Priority Practices Guide at any point during the calendar year in which the performance period occurs.
  • Measure Score: Required to earn a Promoting Interoperability score > 0
  • Clinicians/Groups must attest YES to this measure
• e-Prescribing: At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT.
  • Measure Score: Up to 10 points.
  • Clinicians/Groups must provide numerator/denominator scores for this measure or attest YES to one of the e-Prescribing exclusions
• Provide Patients Electronic Access to their Health Information: For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).
  • Measure Score: Up to 40 points.
  • Clinicians/Groups must provide numerator score > 0 for this measure. No Exclusions apply.
• Support Electronic Referral Loops by Sending Health Information: For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider — (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.
  • Measure Score: 20 points.
  • Clinicians/Groups must provide numerator scores >0 for this measure; attest YES to one of the measure exclusions; OR attest YES to the Health Information (HIE) Bi-Directional Exchange measure
• Support Electronic Referral Loops by Receiving and Incorporating Health Information: For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.
  • Measure Score: 20 points.
  • Clinicians/Groups must provide numerator scores >0 for this measure; attest YES to one of the measure exclusions; OR attest YES to the Health Information (HIE) Bi-Directional Exchange measure
• Health Information Exchange (HIE) Bi-Directional Exchange: New for 2022. The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.
  • Measure Score: 40 points
  • Clinicians/Groups can report YES or TRUE to this measure in place of the Support Electronic Referral Loops by Sending Health Information and Support Electronic Referral Loops by Receiving and Incorporating Health Information measures.
• Immunization Registry Reporting: Now required for 2022. The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
  • Measure Score: 5 points
  • Clinicians/Groups must report YES or TRUE to this measure or attest YES to one of the measure exclusions
• Electronic Case Reporting: Now required for 2022. The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.
  • Measure Score: 5 points.
  • Clinicians/Groups must report YES or TRUE to this measure or attest YES to one of the measure exclusions. OfficeEMR customers will most likely attest to the PI_PHCDRR_3_EX_4 Electronic Case Reporting Exclusion - the MIPS eligible clinician uses CEHRT that is not certified to the electronic case reporting certification criterion at CFR 170.315(f)(5) prior to the start of the performance period they select in CY 2022.

Bonus Measures for the 2022 Reporting Period: 

• Query of the Prescription Drug Monitoring Program (PDMP): For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a Prescription Drug Monitoring Program (PDMP) for prescription drug history, except where prohibited and in accordance with applicable law.
  • Measure Score: 10 bonus points.
• Syndromic Surveillance Reporting: The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.
  • Measure Score: 5 bonus points.

Learn more about the Promoting Interoperability performance category at the qpp.cms.gov.

Follow these steps to view a clinician or group's MIPS Promoting Interoperability score:

1. Select either the Group or Individual Clinician to see the Promoting Interoperability scores for.
   
   
2. Click on the Hammer button under the Promoting Interoperability section of the Dashboard to calculate/refresh the Promoting Interoperability score for the Group/Individual Clinician.
   
   
3. Click on the Measure name for more information about the measure.
   
4. Click Measure Results link to see patient level Measure Results.
   
   
5. View the Patient Measure Results.
   

The goal is for the Group/Eligible Clinician’s Promoting Interoperability score to be as close to 25 / 25 as possible

Measures with a * after them are required to have a score > 0 for the promoting interoperability performance category. These measures include:

• Safety Assurance Factors for EHR Resilience (SAFER) Assessment
• Security Risk Analysis
• e-Prescribing
• Provide Electronic Access
• Referral Loops – Send Health Information AND Referral Loops – Receive & Incorporate Health Information OR HIE Bi-Directional Exchange
• Public Health and Clinical Data Exchange - Electronic Case Reporting and Immunization Reporting

The following measures are available as bonus measures for Eligible Clinician's to add an additional points their Promoting Interoperability score: 

• Query of the Prescription Drug Monitoring Program - 10 Bonus Points
• Public Health and Clinical Data Exchange - Syndromic Surveillance Reporting - 5 Points

MIPS Eligible Clinicians must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary and correcting identified security deficiencies.

• Analysis must be conducted when 2015 Edition CEHRT is implemented and during the reporting period year 01/01/2022-12/31/2022.
• The Office of the National Coordinator for Health Information Technology (ONC) has developed a downloadable Security Risk Assessment (SRA) tool to help guide practices through the process. Access the SRA tool here.
• Select the Attest to completing a Security Risk Assessment for my Office checkbox upon completion for each Clinician.
  
  

• At least 1 permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT.
• This measure is worth up to 10 points towards the clinician’s/group’s Promoting Interoperability score
• The practice must have the Company Setting Use RX HUB on for the duration of the reporting period.
• All printed/electronic prescriptions are in the denominator for the clinician.
• Electronic prescriptions written by the clinician make up the numerator, including Electronic Prescriptions for Controlled Substances.
  
  

• For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law. 
• Eligible clinicians will Attest Yes or Attest No to meeting this measure.
• This measure is worth up to 5 bonus points towards the clinician’s/group’s Promoting Interoperability score.

iSalus has integrated with the Appriss Health PDMP Interface; to see if the interface is available in your state and to obtain a user name and password, fill out the following form from Appriss Health here.

• For at least one unique patient seen by the MIPS eligible clinician:
  • The patient (or the patient-authorized representative) is provided timely (within 4 business days of their appointment start time) access to view online, download, and transmit his or her health information; and
  • The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).
• This measure is worth up to 40 points towards the clinician’s/group’s Promoting Interoperability score

Option 1: Connect Patient with a MyMedicalLocker Account

• From the iScheduler, open the patient or select the Patient's Appointment on the schedule.
  
  
  
• Click on the Patient Index Card Menu and select the MyMedicalLocker Admin option.
  
  
  
• Click on the Connect Patient button.
  
  
  
• Enter the Requested by (the patient or a patient authorized representative's name); either their Email Address or Phone Number and press the Email Token button. The patient will be emailed/texted a Token.
  
  
  
• Ask the patient/rep for the Token that was emailed or texted to them and enter that in the Connect Patient screen.
  
  
  
• Press the Connect Patient button.
  
  
  

Option 2: Print a Welcome to MyMedicalLocker Letter at Patient Check-out

• In the iScheduler, right-click over the patient’s appointment and change the appointment status to Check-Out.
  
  
  
• Click on the Print Queue tab within the Quick Pay screen. If the patient does not already have a MyMedicalLocker connection, a MyMedicalLocker Welcome Letter will display in the print queue.
  
  
  
• Press the Print button and provide the MyMedicalLocker Welcome Letter to the patient
  

• For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider:
  • Creates a summary of care record using certified electronic health record technology (CEHRT); and
  • Electronically exchanges the summary of care record.
• This measure is worth up to 20 points towards the clinician’s/group’s Promoting Interoperability score
• The denominator for this measure is made up of Referral Type Orders placed for the eligible clinician during the reporting period.
  
  
  
  
• The numerator is made up of the patient orders from the denominator where a CCDA Referral Note was sent using DIRECT email to the physician receiving the referral.

To send a referral note using DIRECT follow these steps:

1. Ensure the user sending the DIRECT message has his/her User Provider Connection setup for the Provider the Referral Summary is being sent for. This needs set prior to opening the Task Communication screen. Reset the Task Communication screen if necessary.
   
   
2. Open Task Communication.
   
   
   
   
3. Click on the New menu.
   
   
   
   
4. Select DIRECT Message.
   
   
   
   
5. Select the user to send the message to, enter a subject and message.
   
   
   
   
6. Click on the Attach button.
   
   
   
   
7. Search for the patient.
   
   
   
   
8. Select the Transition of Care option. Set the Requested date to the Referral Order Date. Enter a Reason for the Referral.
   
   
   
   
9. Press the Attach button.
   
   
   
   
10. Press the Send button
    
    

To check receipt of a DIRECT message, follow these steps:

1. Open My Task Communication.
   
   
   
   
2. Click on the Sent Items queue.
   
   
   
   
3. Find your DIRECT message in the Sent Items Queue. Right-click over the message and select DIRECT Status.
   
   
   
   
4. The status must be either 'Accepted' or 'Confirmed' to count towards the numerator of the Referral Loops - Send Health Information MIPS measure.
   
   

• For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.
• The denominator for this measure is made up of new patient encounters during the performance period where a CCDA was attached to the patient's record for the encounter. 
• The numerator is made up of the patient encounters in the denominator where problem list, medication and allergy reconciliation was performed for the encounter during the reporting period. 
• This measure is worth up to 20 points towards the clinician’s/group’s Promoting Interoperability score
• Exclusions:
  • Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2019 would be excluded from having to report this measure.  Or 
  • Any MIPS eligible clinician who receives fewer than 100 transitions of care or referrals or has fewer than 100 encounters with patients never before encountered during the performance period. 
• If an exclusion is claimed for this measure, the 20 points will be redistributed to the other measure within this objective, the Support Electronic Referral Loops by Sending Health Information measure. 

Option 1: Import and Attach CCDA Received from Outside Sources

1. Click on the Reports portal.
   
   


2. Click on the Summary of Care option under the EHR section.
   
   


3. Click on the Import button.
   
   


4. Navigate to the location of the Summary of Care XML file on your computer, select it and press the Open button.
   
   


5. The summary of Care displays. The report will display patients whose demographic data match the data within the CCDA. If the correct patient does not display, click on the Search button to either search for or create a new patient. Click on the correct patient’s name and then on the Attach button to incorporate the summary into the patient’s chart.
   
   


6. Summaries must be associated with the patient's new patient encounter to count towards the measure, select the appropriate patient Appointment to link the referral summary to.
   
   


7. If the incorporation is successful, you will receive an alert the attachment was successful.
   
   


8. The summary is now ready for clinical reconciliation. Incorporated summaries will display in the EHR on the Timeline Summary Screen under the Health Exchange section.
   
   


9. Click on the clinical marker to view the summary. 
   
   

Option 2: Receive and Incorporate CCDA Received via DIRECT Message

1. Open My Task Communication
   
   


2. Incoming DIRECT messages display in the user’s Inbox, click on the Message to open it.
   
   


3. CCDA documents will display as an XML attachment. Click on the .xml Attachment to view the summary.
   
   


4. The Report will display patient’s whose demographic data meet the data within the CCDA. If the correct patient does not display, click on the Search button to either search for or create a new patient. Click on the correct patient’s name and then on the Attach button to incorporate the summary into the patient’s chart.
   
   


5. Summaries need associated with a patient encounter to count towards the EP’s MU measure, select the appropriate patient Appointment to link the referral summary to.
   
   


6. If the incorporation is successful, you will receive an alert the attachment was successful.
   
   


7. Incorporated summaries will display in the EHR on the Timeline Summary Screen under the Health Exchange section. 

• The Clinician must attest Yes or Claim an Exclusion to 2 of the 5 Public Health and Clinical Data Exchange reporting options to qualify for this measure.
• This measure is worth up to 10 points towards the clinician’s/group’s Promoting Interoperability score
• The following public health and clinical data exchange options exist:
  • The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS). See Immunization Reporting
  • The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care setting. See Syndromic Surveillance Reporting
  • The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.
  • The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.
  • The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.

The product's CMS EHR Certification ID is 0015EWX71NYU51A. This ID is required for attesting Promoting Interoperability scores to CMS and Medicaid. You can always access this ID from within the product following these steps:

1. Click on the Reports portal.
   
   
2. Select MIPS Dashboard.
3. The Certification ID displays in the Promoting Interoperability section.  
   

Follow these instructions to print out the practice's promoting interoperability numerators and denominators used for attestation to the MIPS programs:

1. Click on the Reports portal.
   
   
2. Select the MIPS Dashboard report.
   
   
3. Click on the Quality Report button.
   
   
4. Pick the All Providers option.
   
   
5. Select the Download button under the Promoting Interoperability section.
   
   
6. Choose the directory/location on your computer and press the Save button.
   
   
7. The Promoting Interoperability report is now downloaded.
   

Please be sure to familiarize yourself with the following resources for complete information on the QPP MIPS Payment Program:

• Official CMS Quality Payment Program Website
• QPP Participation Status Lookup
• QPP Resource Library (Includes Scoring Guides, User Guides, Webinar Slide Decks and more)
• 2019 MIPS 101 Guide
• 2019 MIPS Scoring Guide

Q: I am sending my referral summaries via DIRECT. Why are they missing from my numerator?

A: In order for your referral summaries to count for the Referral Loops: Send Health Information measure, please ensure you're following these steps and verify the settings/steps below:

1. Ensure the user sending the DIRECT message has his/her User Provider Connection setup for the Provider the Referral Summary is being sent for. This needs set prior to opening the Task Communication screen. Reset the Task Communication screen if necessary. If this setting was not setup before sending the referral summary via DIRECT, you must send a new summary of care.
   
   
   
2. Did you set the Transition of Care summary Requested Date to the Referral Order Date? These two dates must match. If the dates did not match, you will need to send a new summary of care via DIRECT.
   
   
3. Find your DIRECT message in the Task Communications > Sent Items Queue. Right-click over the message and select DIRECT Status. The status must be either 'Accepted' or 'Confirmed' to count towards the numerator of the Referral Loops - Send Health Information MIPS measure.
   
   
   
4. Open the Reports > MIPS Dashboard. Select the provider/group you are looking at. Press the Hammer icon under the Promoting Interoperability section to re-calculate the MIPS PI scores.
   

Q: Why is my Provider/Group's Referral Loops: Receive and Incorporate denominator zero?

A: In order for a new patient visit (a claim with a new patient CPT code present on it during the reporting period) to count towards the Referral Loops: Receive & Incorporate denominator, a CCDA document must be received via DIRECT/imported via the Reports > Summary of Care screen and linked to the patient's new patient appointment when linking the CCD to the patient's chart. Click here for the full instructions on receiving and incorporating CCDA documents into patient charts.