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MIPS 2021 Final Rule: Promoting Interoperability and Improvement Activities Measures


The Quality Reporting Engagement Group recently reported on the Merit-based Incentive Payment System (MIPS) 2021 Final Rule and what some of the changes might mean to your practice.

Promoting Interoperability
The Promoting Interoperability category is worth 25 percent of the total composite score for MIPS.

Practices must report performance measures for a minimum of 90 continuous days. There were not a lot of changes to the category this year, but the Centers for Medicare & Medicaid Services (CMS) did keep the Query of Prescription Drug Monitoring Program (PDMP) and increased the bonus from five points to 10 points for this optional measure. CMS also added an optional Health Information Exchange: Bi-Directional Exchange measure which is completed through a Yes/No attestation and must be reported using certified electronic health record technology (CEHRT) criteria. Additional information on scoring is available in the webinar.

Practices will continue to attest to certain Information Blocking statements in this category and must complete the annual Security Risk Analysis.

CMS will continue to automatically reweight certain clinician types. The full list of clinicians is available in the webinar.

Improvement Activities
The Improvement Activities category remains at 15 percent of the total composite score.

Practices continue to need to submit 40 points of measures to get full credit for the category. At least 50 percent of the Eligible Clinicians (EC) need to participate in each activity for a 90-day continuous period of the Performance Year (PY). Some practices will receive a special status and have their points doubled if they fall in one of the categories, such as being located in a rural area, being a small practice of less than 15 ECs, be a non-patient-facing EC or in a health professional shortage area (HPSA). For example, when reporting on a high-weighted activity, typically worth 20 points, those practices with special status will automatically receive 40 points for completion.

CMS made some modifications to the activities around COVID-19 clinical data, outside of clinical trials. Specifics around the finalized policy are available in the webinar.

MIPS Value Pathways
The implementation for the MIPS Value Pathways (MVP) will be delayed until at least 2022 in response to the COVID-19 Public Health Emergency (PHE).

Extreme and Uncontrollable Circumstances Exception
Practices were allowed to request one or more performance categories to be reweighted to zero. This exception was created because of the COVID-19 PHE. The deadline for an application by practices closed on February 1, but experts believe this hardship will be available again this coming year. Practices must apply for the exception – the hardship exception is not automatic. It is recommended that the practice document that providers experienced an extreme and uncontrollable circumstance outside of your control that prevented you from collecting data for an extended period of time. The documentation would be needed in the case of a CMS audit.

Complex Patient Bonus
The complex patient bonus is added to your practice’s total MIPS composite score at the end of the performance year, and it is based on the medical complexity and the social risk of your patients. Due to the complexities of treating patients during the COVID PHE, the bonus is worth up to 10 points instead of the typical five points.

Alternative Payment Models
If your practice is interested in information about changes or modifications made to Alternative Payment Models (APM) reporting, visit the webinar.

The information in this article was taken from the MIPS 2021 Final Rule webinar held on January 27, 2021.

The Quality Reporting Engagement Group has helped 99 percent of the practices they have partnered with reach the Exceptional Performer status. The team can help practices with consulting on specific measures and methods of submission or even help with handling the submission before the March deadline. The team can be reached at