Quality Improvement for Institutions
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Frequently Asked Questions

Using the ACC and Veradigm's PINNACLE Registry and the Diabetes Collaborative Registry (Outpatient Registries) for the Merit-Based Incentive Payment System (MIPS) Program

Using the Outpatient Registries for 2020 Quality Payment Program Year

The Merit-based Incentive Payment System (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, Promoting Interoperability and Cost. Each component is a weighted score that will contribute to your overall payment adjustment in 2022 for participation in the 2020 QPP program year.

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 single Qualified Clinical Data Registry (QCDR) reporting option for MIPS 2020. 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. Click here for directions on how to complete an electronic data release consent form (eDRCF).

Eligible clinicians who are actively submitting their patient data to PINNACLE and/or the Diabetes Collaborative Registries can request that the outpatient registry team report their 2020 MIPS data on their behalf. The outpatient registry team 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 2020 MIPS data on their behalf to CMS:

  • Practices must contract with PINNACLE and/or the Diabetes Collaborative Registries by Oct. 2, 2020.
  • Practices must be actively submitting data to the registries through their EHR system integration by Nov. 2, 2020.
    • 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 quality 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 Outpatient registry team do 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 1-866-288-8292 between 7 a.m. and 7 p.m. CT.

Group Practice Reporting for MIPS 2020

In 2020, 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 quality measures, including one outcome measure or one high-priority measure and report for at least 70 percent of the group practice’s patients. In order to successfully report data for Improvement Activities, at least 50% of the providers within the group must participate in that activity.

Simply reach out to your dedicated client account manager to inform them your practice is reporting as a group for 2020.  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 Outpatient Registry team 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 2020

If a provider elects to submit data to CMS using the QCDR, the Outpatient Registry team 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 2020 CMS-approved MIPS measures can be found here. Detailed specifications for non-MIPS (QCDR) measures also are available here.

Patient encounters that occurred between Jan. 1, 2020 and Dec. 31, 2020. Eligible clinicians and groups are required to report a full year of quality data in 2020.

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, if 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. Please note, only one submission method can be used to report the Promoting Interoperability performance category.

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 feedback 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.

Calculating 2020 MIPS Incentives/Adjustments

In 2020, if an individual clinician or group does not satisfactorily report or participate while submitting MIPS data, an automatic payment adjustment of up to negative 9 percent will apply to Medicare Part B payments in 2022. CMS makes the final payment adjustment decisions not ACC or Veradigm.

Practices should be able to use the PINNACLE/Diabetes Collaborative performance reports to gauge their likelihood of meeting 2020 MIPS requirements. Practices also can use the MIPS Dashboard within the Physician Dashboard to gauge their performance in each performance category. The ACC and Veradigm cannot guarantee safety from the MIPS payment adjustment because CMS ultimately makes this decision.

2020 MIPS final scores should be available in July 2021. 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, 2022.

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

2019 MIPS Status

CMS will review and calculate final performance scores by July 1, 2020, to determine whether clinicians and groups satisfactorily met the 2019 MIPS requirements. The data submitted in 2019 will be used to calculate the payment adjustment applied to 2021 Medicare Part B payments.

Create an Enterprise Identify Management (EIDM) to access your 2019 MIPS Performance Score and Quality Resource Use Report (QRUR).


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