Quality Improvement for Institutions
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Frequently Asked Questions

Using PINNACLE Registry and the Diabetes Collaborative Registry (Outpatient Registries) for the Merit-Based Incentive Payment System(MIPS) Programs

Using the Outpatient Registries for 2018 Quality Payment Program Year

MIPS is one of two tracks offered by CMS to meet the requirements of the Quality Payment Program (QPP). MIPS is a single program that replaces PQRS, EHR Incentive Program (Meaningful Use) and the Value-Based Modifier. Practices will earn a payment adjustment based on four performance categories: Quality, Improvement Activities, Advancing Care Information and Cost. Each component is a weighted score that will contribute to your overall payment adjustment in 2020.

2018 is the first year in which Cost will be incorporated into the final MIPS composite performance score.

Eligible clinicians who provide clinical care and bill under Medicare Part B FFS (Fee-For-Service) can participate in MIPS through the QCDR. MIPS-eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.

Click here to see if you are eligible to participate in MIPS!

The Outpatient Registries are an approved Qualified Clinical Data Registry (QCDR) reporting option for MIPS. A QCDR is defined as a CMS-approved entity that has successfully completed a rigorous qualification process to collect medical and/or clinical data for the purpose of patient and disease tracking to foster quality improvement for patients. Both Outpatient Registries are considered a single QCDR for 2018.

Eligible clinicians who are actively submitting their patient data to PINNACLE and/or the Diabetes Collaborative Registries can request that ACC report their 2018 MIPS data on their behalf. The ACC will submit eligible clinician’s data for MIPS only if the eligible provider and/or group completes an electronic data release consent form (eDRCF) by the ACC-specified deadline. The eDRCF allows the QCDR to release quality measure data to CMS on the clinicians’ behalf. Regardless of submission method, CMS requires consent for the ACC to submit data on your behalf.

Providers must complete the following three steps before PINNACLE and/or the Diabetes Collaborative Registries can report 2018 MIPS data on their behalf to CMS:

  • Practices must contract with PINNACLE and/or the Diabetes Collaborative Registries by Aug. 31, 2018.
  • Practices must be actively submitting data to the ACC via their EHR system integration by Oct. 1, 2018.
    1. Only clinicians who submit an eDRCF for MIPS reporting will have their data submitted to CMS.

For more information, existing registry participants should contact their dedicated account manager or the NCDR participant support team at ncdr@acc.org or 1-800-257-4737. New and potential participants can learn more about the PINNACLE Registry and Diabetes Collaborative Registry here.

Providers must complete the following three steps before PINNACLE and/or the Diabetes Collaborative Registries can report 2018 MIPS data on their behalf to CMS:

  • Practices must contract with PINNACLE and/or the Diabetes Collaborative Registries by Aug. 31, 2018.
  • Practices must be actively submitting data to the ACC via their EHR system integration by Oct. 1, 2018.
    1. Only clinicians who submit an eDRCF for MIPS reporting will have their data submitted to CMS.

For more information, existing registry participants should contact their dedicated account manager or the NCDR participant support team at ncdr@acc.org or 1-800-257-4737. New and potential participants can learn more about the PINNACLE Registry and Diabetes Collaborative Registry here.

No, ACC membership is not required. The QCDR is designed to assist cardiovascular, internal medicine and family physician practices in improving cardiac care for their patients. Your practice must, however, be able to report at least six performance measures including one outcome measure or one high-priority measure to CMS.

Yes, a practice may request that the QCDR submit MIPS data on behalf of all clinicians in the practice. If a practice is reporting its clinicians as individuals, each individual provider must complete his/her own eDRCF for MIPS data submission. All clinicians at a given practice are not required to participate in the QCDR for MIPS reporting.

If reporting MIPS data through another CMS program (such as the Medicare Shared Savings Program, Comprehensive Primary Care Initiative or Pioneer Accountable Care Organizations), you are not eligible to submit MIPS data via the PINNACLE and Diabetes Collaborative QCDR.  Please note, some groups may have clinicians participating under a Next Generation ACO and MIPS-eligible clinicians not in the ACO billing, under the same Taxpayer Identification Number (TIN), also referred to as a “split TIN.” In this instance, the MIPS-eligible clinicians and practices who are not participating in the Next Generation ACO are still required to report to MIPS and are eligible to report through a QCDR.

The ACC does not have access to information on whether your practice is registered as an ACO. The best way to find out is to call the CMS QualityNet Help Desk at 1-866-288-8912 between 7 a.m. and 7 p.m. CT.

Group Practice Reporting for MIPS 2018

In 2018, group practices of two or more eligible clinicians can participate as a group practice. Group practice level reporting is when performance data for all clinicians in the practice is aggregated at the TIN level. All clinicians under the TIN will receive the same score. Solo practitioners are not eligible to report as a group.

GPRO reporting may make it easier for providers to meet MIPS reporting requirements. If the entire practice meets the requirements, CMS considers all clinicians in the practice to be participating in MIPS successfully. For example, a practice with two eligible providers can meet the requirements if the first provider reports 40 percent of his or her patients and the second provider reports 60 percent of his or her patients.

The reporting requirements for group practice reporting are the same as those for individual reporting. Group practices must submit six measures, including one outcome measure or one high-priority measure and report for at least 60 percent of the group practice’s patients.

Simply reach out to your dedicated client account manager to inform them your practice is reporting as a group for 2018.  CMS no longer requires group practices to self-nominate under the QPP.  Please note, if a practice decides to report their Quality data using the CMS Web Interface for MIPS, there are deadlines established by CMS. Please review the QPP webpage for additional information. 

The ACC highly recommends group practice reporting for practices over five providers and/or multispecialty groups. If you need help figuring out the best option for you, you can talk to your client account manager or email us at ncdr@acc.org.

Note: For group practice reporting you only need to complete one eDRCF per TIN.

Data Submission for MIPS 2018

If a provider elects to submit to CMS using the QCDR, the ACC will provide CMS with quality measures data for six individual measures for that provider. Practices will select their own six quality measures for submission via the Physician Dashboard.

A listing of the 2018 CMS-approved MIPS measures can be found on the ACC website. Detailed specifications for non-MIPS (QCDR) measures also are available on the ACC website.

Patient encounters that occurred between Jan. 1, 2018 and Dec. 31, 2018. Eligible clinicians and groups are required to report a full year of quality data in 2018. There is a possibility this could change.

Practices are required to submit 100 percent of patient encounters that meet inclusion criteria. Generally, that includes face-to-face office visits for patients with coronary artery disease, heart failure, hypertension, diabetes and/or atrial fibrillation.

No, participation in registry data collection requires providers and practices to submit all data elements on all patients that meet the inclusion criteria, regardless of payer status, not just the select MIPS measures.

A clinician or practice may submit for MIPS through multiple methods, as long as they do not plan to submit Quality using the CMS Web Interface as a group practice or are required to use the CMS Web Interface as a participant in an Accountable Care Organization (ACO). Each reporting mechanism must encompass a complete reporting period and must include the minimum reporting requirements.

Yes, eligible clinicians and groups will select their own measures for submission. If you decide to report using the QCDR, there are several available resources to review your performance, including monthly performance reports from PINNACLE and/or the Diabetes Collaborative Registries that detail adherence to clinical measures across all patient encounters that meet inclusion criteria. Most MIPS measures have an analogous PINNACLE and/or Diabetes Collaborative Registries measure, which you can use to gauge performance. Click here for a crosswalk of MIPS measures with the standard PINNACLE/Diabetes Collaborative measures, where applicable. You can also review your performance at the group or individual provider level via the Physician Dashboard. Please click here to login. If you have questions regarding your measure performance, contact your client account manager immediately. It is highly recommended you do not wait until Q4 of 2018 to request mapping refinements.

Calculating 2018 MIPS Incentives/Adjustments

In 2018, if an individual clinician or group does not satisfactorily report or participate while submitting MIPS data, an automatic payment adjustment of up to negative 5 percent will apply to Medicare Part B payments in 2020. CMS makes the final payment adjustment decisions not the ACC.

Practices should be able to use the PINNACLE/Diabetes Collaborative performance reports to gauge their likelihood of meeting 2018 MIPS requirements. Practices also can use the MIPS Dashboard within the Physician Dashboard to gauge their performance in each performance category. The ACC cannot guarantee safety from the MIPS payment adjustment because CMS ultimately makes this decision.

CMS has stated that 2017 MIPS final scores will be available starting July 1, 2018. A similar timeline is expected for the 2018 MIPS year, with the MIPS final scores being available in July 2019. Clinicians and practices will receive their feedback and scores by logging into the CMS QPP Portal using their Enterprise Identity Management (EIDM) credentials. For assistance with accessing your account or creating a new username, call the CMS Help Desk at 1-866-288-8292 or review the user guide. Payment adjustments will be applied to Medicare Part B claims starting on January 1, 2020.

More information on ACC’s Outpatient Registries – including data collection, research opportunities and MIPS participation – is available on our website.


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