Quality Measures & Telehealth

Just before the 4th of July holiday weekend, CMS released new guidance for which eCQMs can be used during a telehealth visit for Reporting Year 2020. This unexpected update was the result of questions regarding if home-captured data was “good enough” for Quality Measures. Fortunately, out of the 47 eCQMs that exist, a total of 42 are telehealth allowable. As with everything, there is a caveat: some measures may require an in-person element that cannot be achieved fully with just telehealth. So while an eCQM is eligible, there may be an extra step required to complete the measure.

Measure Highlights

While the complete list available here, we do want to highlight the ones that we find most commonly used by practices:


  1. 50v8 – Receipt of Specialist Report
  2. 68v9 – Documentation of Current Medications
  3. 122v8 – Diabetes Hemoglobin A1c Poor Control
  4. 128v8 – Anti-depressant Medication Management
  5. 135v8 – Heart Failure Medication Therapy (ACE inhibitor or ARB or ARNI therapy)
  6. 138v8 – Tobacco Screening & Cessation
  7. 139v8 – Falls Screening
  8. 156v8 – Use of High-Risk Medication in the Elderly (inverse measure)
  9. 159v8 – Depression Remission at 12 months
  10. 161v8 – MDD Suicide Risk Assessment
  11. 165v8 – Controlling High Blood Pressure
  12. 347v3 – Statin Therapy for Treatment of CVD

NOT Allowed:

  1. 22v8 – Screening for High Blood Pressure & Follow-up
  2. 69v8 – BMI Screening & Follow-up
  3. 157v8 – Medication & Radiation Paint Intensity Quantified
  4. 129v9 – Prostate Cancer Overuse of Bone Scan
  5. 133v8 – Cataracts 20/40 or Better Within 90-days Following Surgery

What About MIPS CQMs?

eCQMs that have a MIPS CQM equivalent (formerly called Registry Measures) are also telehealth eligible/ineligible! Remember, the difference between the measure sets is: targeted population and (usually minor) differences in their formulas. Generally, however, the MIPS CQMs are identical in nature to their matched eCQMs.

If you have a MIPS CQM (there are 196 of them) you can safely assume it is NOT telehealth eligible if it is not on the list. If you are relying on telehealth visits and have MIPS CQMs not on the list, you will need to adjust your measures.

What About Specialty Registry Measures?

The guidance released only applies to measures that CMS oversees: MIPS CQMs & eCQMs. The onus is on the Qualified Registry to determine if a telehealth visit and their data standards are an equitable match. If you have a specialty registry, that you are using to report MIPS Quality, be sure to consult with them about this.

Going Forward

CMS has said that this list of CQMs for 2020 is final. However, they did also release a list for 2021 which has FEWER (39) measures allowed. Fortunately, those three extra measures are not common. It is important to note that this list is not final and may change between now and Jan 1, 2021.

As the 2021 list is updated we will provide you our analysis if anything significant changes. At this point, however, we do not believe that it will change radically.


The rush to telehealth brought about questions that almost no one was asking: “What Quality Measures can be done outside the clinic?” CMS has responded with a well-crafted list of measures.

As always, CMS reserves the right to change the MIPS program to adapt to the health community’s needs. Though it appears that they are finished changing the program for 2020. Historically, in late July, CMS releases a Proposed Rule that becomes final in late-Oct/early-Nov. Therefore, SHP anticipates additional changes to the MIPS program for 2021, but no further major changes to the program for 2020.

Practices, particularly those who are relying on Telehealth, should re-evaluate their Quality Measures against this list. If you find that you were using a measure that is not eligible, you may want to consider requesting an Extreme & Controllable Circumstances Exception for the Quality Category.

If you are not sure if you should file an ECCE, or if you want assistance with picking your eCQMs, contact your SHP Representative and they will get you in touch with our MIPS expert.

MIPS Reporting Year 2020 Guidance Update

MIPS Reporting Year 2020 Guidance Update

After weeks of waiting, CMS has finally updated its MIPS guidance around the Reporting Year 2020 (RY2020). While CMS may make additional changes, this is the first major change for RY2020 we have seen thus far. For 2020, physicians and groups reporting for MIPS may submit an Extreme & Uncontrollable Circumstances Application to have some or all the MIPS categories reweighted to 0%. You must justify how COVID-19 has harmed your ability to achieve the category (or categories) you are asking to have reweighted.

Unlike the last-minute automatic reweight of RY2019, this will require effort on your organization’s part. You must provide examples showing:

  • How the pandemic prevented you from collecting necessary MIPS data for a category (or categories) (such as seeing patients only via telemedicine and no reliable method of collecting Quality Category data)
  • How the pandemic will prevent you from scoring a category (such as missing 3 months’ worth of Quality Category data)
  • How the pandemic impacted your normal business process that would affect your cost measures or other administrative claims measures (such as unable to send claims due to lack of enough billing staff)

SHP’s Recommendation

We recommend that if you intended to submit for RY2020 and you feel your data is complete enough to score well, continue to move forward with that plan. A reweight request of a category may result in a lower score than desired. A total reweight of MIPS will result in a score of 0, with penalty avoidance, but may harm your score on Physician Compare: https://www.medicare.gov/physiciancompare/

That said, if you do feel like a reweight will help your organization and you feel that you can justify the request to CMS, follow the instructions here: https://qpp.cms.gov/mips/exception-applications#extremeCircumstancesException-2020

As always, SHP is here to help you with your Quality Payment Program participation questions, and we will bring you timely information regarding any changes to the MIPS program for 2020 and beyond.

PQRS to MIPS Quality Metric Mapping

The 2,171-page final rule contains several differences that crosswalk existing PQRS measures to new finalized metrics. The simplest way to ensure your PQRS-to-MIPS transition goes smoothly is to search each quality metric and data submission method here.

Several important tables for your reference from the final rule:

  • Table A (Page 1,902) outlines each of the available MIPS Quality measures.
  • Table D (Page 2,019) explains each of the brand-new MIPS Quality measures.
  • Table F (Page 2,114) contains each of the PQRS measures that are no longer available in the MIPS Quality Program.
  • Table G (Page 2,126) identifies PQRS that were subjected to “substantial changes,” for the MIPS Quality Program.


Keep in mind, to submit enough data for a “moderate positive adjustment,” in the 2017 Performance Year, you need to submit 6 measures, including one outcome measure, or one high-priority measure for a minimum of a continuous 90-day period. Specialists can also report specialty-specific sets, some of which contain fewer than 6 measures but many include 10+ measures.

MIPS: Simplifying The Merit-Based Incentive Payment System

The Merit-Based Incentive Payment System (MIPS) is the future value-based program for Medicare Part B Providers that should be considered the default Medicare payment program beginning January 1, 2019 with a two-year look-back, therefore truly beginning in 2017. This program rolls up Meaningful Use (MU), the physician quality reporting system (PQRS), and the value-based payment modifier (VBM) into a single program while adding resource-use metrics and Clinical Practice Improvement activity adjustments.

Fee-For-Service Basics

Currently, physicians are reimbursed on a fee-for-service basis, meaning they are paid for each office visit, procedure, or diagnostic test they perform. To maintain financial sustainability in a time of declining reimbursement, physicians are externally influenced to see more patients, perform procedures with higher reimbursement rates even if lower-cost treatment options are equally as effective.

MIPS Basics

CMS will attempt to control Medicare spending by providing pro-active thresholds at the beginning of a reporting period to guide “Eligible Providers” to understand their intended targets. These targets will result in a composite score in 2019 (These weighted categories will be adjusted in the following years):
30 points – Quality (PQRS)-Improvement-Incentives Included
30 points – Resource Use (VBM)
25 points – EHR Meaningful Use (MU)
15 points – Clinical Practice Improvement Activities

In the 2017-2018 performance years, the following Medicare Part B providers are considered eligible professionals:
• Physicians
• Physician Assistants
• Nurse Practitioners
• Clinical Nurse Specialists
• Nurse Anesthetists

2019 and beyond, the following Medicare Part B providers will become eligible professionals:
• Physical & Occupational Therapists
• Speech-language pathologists
• Audiologists
• Nurse Midwives
• Clinical Social Workers
• Clinical Psychologists
• Dietitians and Nutrition Professionals

Exempted providers include:
• 1st year Medicare providers
• Participants in Alternative Payment Models (APMs)
• Providers not meeting the “low volume threshold” (Yet to be Defined-Estimated to be proposed in July 2016)

MIPS Reimbursement Impact

Until now, PQRS, MU, and the VBM penalties were largely considered tolerable by many physicians as the initial capital necessary to pursue uncertain rewards largely deterred many providers from participating. Similarly, the vast range of providers falling into “neutral tiers” of these programs allowed physicians to largely ignore their effects; however, the MIPS program is completely budget-neutral, only providers earning the exact threshold score to receive no payment adjustment. Thus, almost every eligible provider will either experience a positive or negative adjustment as the penalized providers will fund the positive adjustments for the providers exceeding the composite threshold.

  MIPS Graphic

The 2019 payment-year reflects the 2017 performance year of MIPS. 2018 payment-year will continue to reflect the 2016 performance-year through the separate MU, VBM, and PQRS programs.
The “x” multiplier represents a budget-neutrality factor which provides a bonus-incentive for the highest performing MIPS-providers to earn up to 3x the maximum bonus % each year (Up to 12% in 2019). Keep in mind, CMS contains Medicare costs through the funding the of MIPS “winners” positive adjustments with the “losers” negative adjustments. Furthermore, MIPS scores will be publicly reported on Medicare’s Physician Compare site providing yet another elusive effect considering how these scores may effect patients’ choice of providers in the not-so-distant future.

How do I start preparing for the MIPS program?

85% of the MIPS score reflects the performance measuring mechanisms of MU, PQRS, and VBM. Continuing to focus on these programs by organizing administrative efforts to improve efficiency will assist in your ability to report most successfully. CMS also released the first set of Core Quality Measures signaling a much-needed unification of quality reporting mechanisms amongst payers, we recommend you follow this similar trend closely. If you’re not proactively planning, it is only a matter of time before your reimbursement penalties become someone else’s bonus checks. Stay tuned for further updates.

Everything to Know about SGR Repeal & MIPS Implementation

Congress has finally passed legislation to permanently repeal the SGR formula that was being used to calculate the Medicare Physician Fee Schedule (MPFS). After years of temporary patches to the SGR to prevent double digit cuts to the Medicare physician schedule, Congress has implemented a new system that will be used to calculate the annual MPFS. What do these changes mean for you?

Conversion Factor

The SGR conversion factor has been replaced with the following conversion factors:

January 1-June 30, 2015: 0.0% conversion factor
July 1-Dcember 31, 2015: 0.5% conversion factor
2016-2019: 0.5% conversion factor for each year
2020-2025: 0.0% conversion factor for each year
2026 and beyond: The conversion factor applied will be based on which quality track a physician has chosen:
Merit Based Incentive Payment System (MIPS): 0.25%
Alternative Payment Model (APM): 0.75%
Obviously many factors go into the formula used to calculate the Medicare Physician Fee Schedule, including relative work units, geographic price indices, etc. This legislation stabilized the conversion factor to prevent an overall negative update to the MPFS; however, the other factors may still result in annual positive/negative updates to Medicare reimbursement.

Quality Tracks

With this legislation, Congress has established a framework that will use two different tracks, the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Model (APM), to tie your Medicare reimbursement to Quality/Cost Containment. While the MIPS and APM acronyms might be new, they represent a continuation in the direction that CMS has been headed for several years: Quality Purchasing (as evidenced in the EHR Meaningful Use, PQRS, Value Based Purchasing, etc) and Innovation (ACOs, Medical Homes, bundled payment initiatives).

Before delving into the specifics of each track, please be aware that the MIPS and APM tracks will not take effect until 2019. The current quality programs in place for CMS will continue operating between 2015 and 2018: EHR Meaningful Use, Physician Quality Reporting System (PQRS) and Value Based Purchasing.

Then, starting in 2019, eligible physicians will have to choose one of the Quality Tracks, MIPS or APM, and their Medicare reimbursement will be adjudicated according to the track that they have chosen.

Merit-Based Incentive Payment System (MIPS)

For physicians that select the MIPS track, a methodology will be used to assess their total performance for Medicare beneficiaries. Each MIPS eligible physician will receive a composite quality score for each performance period.

1) Payment Adjustment (either positive or negative):

a) Annual Maximum Adjustment:
2019: -4% to +12%
2020: -4% to +15%
2021: -7% to +21%

2022 and beyond: -9% to +27%
b) The MIPS Payment Adjustments are scheduled to be budget neutral; therefore, the positive and negative adjustments are supposed to balance one another.
2) How is the MIPS Composite Score Tabulated?:

a) 30%: Quality; such as the current PQRS Measures
b) 30%: Resource Use: CMS will use this category to analyze the relative cost of treatment for Medicare beneficiaries.
c) Resource use represents the greatest deviation from current CMS initiatives as CMS will be developing “Care Episode” and “Patient Condition” methodologies to compare similar patients/care episodes and measure the cost of care provided to beneficiaries.
d) 15%: Clinical Practice Improvement Activities, such as expanded practice access (after-hour access); population management; care coordination, etc.
e) 25%: Meaningful Use of Certified EHR Technology

Alternative Payment Model (APM)

Healthcare reform established the CMS Centers of Innovation, who have been running the innovative delivery systems for Medicare, including the Medicare Shared Savings ACOs, the Pioneer ACOs, Bundled Payment Initiatives, etc. Congress is re-committing to the continued development of these models by establishing a APM track for physician reimbursement.

1) Payment Adjustment: An eligible professional who is participating in a Qualified APM will be paid an amount equal to 5% of their aggregate payment amounts for such covered services during the previous year.

2) How Will CMS Determine What is a Qualifying APM?

a) Eligible APMs are payment models that:
i) Require participants to use certified EHR technology.
ii) Provides for payment based on quality measures.
iii) Bears financial risk for monetary losses.

iv) Is a Medical Home expanded under the CMS Innovation model.
b) In addition to the above requirements regarding the APM payment model structure, the legislation requires that to qualify for the APM Financial Incentive, the eligible professional must have a set percentage of their payments be attributable to the services that they provide in the APM:

i) 2019 & 2020: At least 25% of payment from Medicare were attributable to services furnished through the APM.
ii) 2021 and 2022: Starting in 2021, physicians can combine Medicare and all-payer APMs. At least 50% of payments have to be attributable to services furnished through APMs, including at least 25% for Medicare.
iii) 2023 and beyond: In 2023, physicians can continue combining Medicare and all-payer APMs. At least 75% of payments have to be attributable to services furnished through APMs, including at least 25% for Medicare.

CMS acknowledges that many of the current models developed under the CMS Centers for Innovation have focused on larger groups of primary care physicians; therefore, this legislation mandates that CMS develop and test APM models that will that focus on specialist services/groups with 15 or fewer eligible professionals/Title XIX (Medicaid/CHIP).


While the SGR repeal legislation outlined the broad programs that will be incorporated into the Medicare Physician Fee Schedule (MPFS), much is still uncertain as CMS still has to determine how they will put the MIPS and APM tracks into operation. With the current programs remaining in place through 12/31/2018, it is unlikely that we will receive definitive guidance on how these tracks will work prior to 2017.

We will continue monitor CMS’s development of the MIPS and APM tracks to share with our members. If you have any questions, please contact our office. Thank you.