Last month’s blog discussed MIPS reporting under the Quality Payment Program (QPP). Let’s take a deeper look at the MIPS Promoting Interoperability (PI) and Improvement Activities (IA) categories. As the end of the performance year approaches, make sure you’re not overlooking these categories that together make up 40% percent of your overall MIPS composite score. The 2023 minimum threshold to avoid a negative adjustment is 75 total points, so reporting these categories is important toward reaching that goal.
The Promoting Interoperability performance category promotes patient engagement and electronic exchange of information using certified electronic health record technology (CEHRT) and is weighted at 25% of your MIPS composite score. PI measures must be reported for a consecutive 90-day period during the reporting year. Clinicians who report PI must use a CEHRT that is certified to the 2015 Edition Cures Update. The CEHRT must be in place by the first day of the performance period, but only needs to be certified by the last day of the performance period. As in previous years, certain clinician types and special statuses will automatically have their PI category reweighted. Beginning in 2023, the following clinician types will no longer be automatically reweighted and are therefore required to report PI data: nurse practitioners, physician assistants, CRNAs, and clinical nurse specialists. There are instances where clinicians can submit a MIPS Promoting Interoperability Performance Category Hardship Exception application. You have until January 2, 2024 to submit the application if you are experiencing any of the qualifying circumstances.
Clinicians should review the PI category requirements as soon as possible. While most measures will be a simple yes/no attestation or numerators/denominators pulled from your EHR, some measures (like the Security Risk Analysis) require additional work. Remember, you must report all measures, or you’ll receive zero points in this category. Some measures have exclusions, which can be claimed if they don’t apply to your practice. If claiming an exclusion, that measure’s points are reweighted to another PI measure.
Improvement Activities are worth 15% of your MIPS composite score and can be a relatively painless way to earn additional points for your final score. Activities have a minimum of a continuous 90-day performance period for 2023 unless otherwise stated in the activity description. Each activity must be performed in 2023, but multiple activities don’t have to be performed during the same 90-day period. There are 40 maximum points in this category and activities are either medium- or high-weighted. For most clinicians, medium-weighted measures earn 10 points and high-weighted earn 20 points each (unless you have a special status, then those points are doubled). There are some caveats to reporting these measures so read through the measure instructions – some have limitations on how many years they can be reported, some require a longer reporting period than 90 days, and if reporting as a group, at least 50% of clinicians in a group must report the same activity. When you attest to an activity, you don’t need to submit your documentation, but you will have to keep it for six years in case you’re audited by CMS.
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