Reporting

2024 is winding down and we should be getting ready to report our 2024 performance to CMS. A common question that keeps popping up is: “Am I required to report MIPS for 2024?”

Any bonus or penalty for your 2023 reporting period will be reflected in your 2024 Medicare Payments. CMS has released the scores and and payments for 2025 payment year.

The year is 75% complete so now is CRUNCH time for many providers participating in the MIPS program for 2024. Many of the measures you report on are ‘Once Per Reporting Period’.   That means you only need to meet the measure on one visit for each patient during 2024. Even if you failed to meet measures prior to today, by making sure you meet the quality measure the next time the patient walks in the door, you get credit for that measure.

The Centers for Medicare & Medicaid Services (CMS) added new 2022 Quality Payment Program (QPP) performance information for doctors, clinicians, groups, virtual groups, and Accountable Care Organizations (ACOs) to clinician and group profile pages on the Medicare.gov compare tool and in the Provider Data Catalog (PDC).

CHECK YOUR FEEDBACK REPORTS NOW! You have until October 11, 2024 to request a targeted review. Now Available: 2023 MIPS Performance Feedback, 2023 MIPS Final Score, and 2025 MIPS Payment Adjustment Information

One of the aspects to score on Promoting Interoperability is Numerators and Denominators. There are five components to Numerators and Denominators: E-prescribing, Provide Patients Electronic Access to Their Health Information, Support Electronic Referral Loops by Receiving and Reconciling Health Information, Support Electronic Referral Loops by Sending Health Information and Bidirectional Health Exchange.

For promoting interoperability, you need to report to at least two registries. There are five different types of registries that you can report to: Clinical data registry, Immunization Registry Reporting, Syndromic Surveillance Reporting, Electronic Case Reporting and Public Health Registry Reporting.

For promoting interoperability, you have to attest to several items. There is ONC-ACB Surveillance Attestation, ONC Direct Review Attestation, Prevention of Information Blocking Attestation, Security Risk Analysis, and High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER Guides)

Measure 317 is to have the office screen for high blood pressure. If the blood pressure is considered to be high, there must be a follow-up and documentation of the follow-up.

For Traditional MIPS you must submit 6 quality measures. You can earn up to 10 points for each quality measure. This means your maximum score for quality in the MIPS program is 60 points. Many providers automatically assume that if they have a performance of 95% on a MIPS quality measure, they will earn 9.5 out of a possible 10 points for that measure. That assumption is not always true.