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2017 MIPS Checklist
Revision: January 9, 2018 © 2017 General Electric Company. Proprietary and Confidential.
TIMEFRAME TASKS
(Please note this checklist is posted on the Quality Reporting Community (CPS, CEMR) and may be updated periodically) What can I be
doing now? Preparation
Install CQR Upgrade to desired service pack and/or third party versions Keep up-to-date on the monthly Knowledgebase releases Monitor CQR ingestion Assign/Confirm Source of Payment (SOP) codes for all insurance carriers
Learn about MIPS Research MIPS Confirm Eligible Clinicians Pick Your Pace for Participation
Choose Measures ACI Performance and Bonus Measures Quality Measures Improvement Activities Regularly monitor measures in CQR
By June 30, 2017 Investigate and Choose your MIPS submission method
By July 1, 2017 If necessary, file for 2016 Meaningful Use Hardship (standard application)
September 2017 By Dec 1, 2017
CMS will send 2016 PQRS feedback reports and make Quality Resource and Usage Reports (QRUR) available Deadline for submitting requests for an Informal Review of 2016 PQRS and Value Modifier results
Oct 1, 2017 If necessary, file for 2016 Meaningful Use Hardship (first-time EPs that never attested for MU but will in 2017 for MIPS)
Oct 2, 2017 Deadline to start your reporting period if you want to report a minimum of 90 days
Oct 24, 2017 to Jan 12, 2018
If using QSS, Enroll: Automated Process in CQR Sign MQIC Agreement (if you are not an existing member) and/or QSS Agreement Enroll individual clinician(s) and MIPS group(s) Include / Exclude clinician(s) from MIPS group(s) Sign and return the QSS Contract Order to sales (requires manual submission) Enter/Validate provider information in CQR and request consent forms (required for all providers for QSS 2017 to add MIPS)
Jan 17, 2018 to Mar 2, 2018
(CPC+ deadline is 2/2)
If using QSS, Authorize Submission Select measures and Authorize provider(s) and/or group(s) Confirm completion of authorizations Receive confirmation email from GE Healthcare and validate provider list
By Mar 31, 2018 Attest with CMS (either via QSS or alternative) Jan 1, 2019 CMS positive or negative adjustments start
Request Help GE Healthcare Services (CPS, CEMR), Quality Payment Program Service Center: 1-866-288-8292, [email protected]
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Install CQR 1. Contract with GE Healthcare or your Value-Added Reseller.
• GE Email: [email protected]
2. With a signed contract, a GE Healthcare Install Consultant can be scheduled to perform the install of CQR and the Qvera Interface Engine, QIE. QIE is a required component to export your data to CQR.
3. An EMR Consultant will provide an introductory education on the use of CQR.
Note: At a minimum, CQR should be installed a month prior to the beginning of your desired reporting period. There are many variabilities to consider
like number of clinicians, number and type of specialties, third party solutions, and which measures are being chosen to report on. It can take
considerable effort to learn each of the measures, decide which ones to use, perform the necessary software setup, decide on and test applicable
workflows, train clinicians, and then track adherence to those workflows. Improving performance on Medicaid MU or MIPS measures is an evolutionary
process. The earlier you start investing in monitoring your performance and adapting based on results, the more likely you’ll be able to benefit from
positive payment adjustments from CMS, or at a minimum, avoid negative payment adjustments.
Upgrade to desired service pack and/or third party versions 1. Review our 2017 Software Requirements (CPS, CEMR) document. 2. Review our MIPS and CPC+ 2017 Group Reporting FAQ (CPS, CEMR) for software requirements. 3. Schedule or prepare for upgrade 4. Perform upgrade or contract with GE Healthcare or your Value-Added Reseller.
• GE Email: [email protected]
Keep up-to-date on the monthly Knowledgebase (KB) releases
Knowledgebase updates occasionally include new value-set mappings that can impact measures depending on your workflows and terms used. See the
Mapping Data for Meaningful Use chapter in the Quality Reporting Guide and our KB release notes that are published with every KB update for more
information.
Preparation
Install CQR
Upgrade to desired service pack and/or third party versions
Keep up-to-date on the monthly Knowledgebase releases
Monitor CQR ingestion
Assign/Confirm Source of Payment (SOP) codes for all insurance carriers
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Our April 2017 KB included 2017 value set data. These values sets were optional and required manual installation. Our July 2017 KB defaulted the
installation of 2017 value set data. Once installed, they replaced the 2016 value sets. Customers that may still be attesting for 2016 Medicaid will want
to follow the KB instructions for re-installing the 2016 value set data and when ready, allow a future KB to install the 2017 value set data.
Note: For customers on a version lower than CPS 12.0.13 or CEMR 9.8.13, value set updates only address data that is sent to CQR from that date
forward. To have 2017 value sets go back to January 1, 2017, run the script that is documented in Knowledgebase release notes in the Updating CQR
with data mapping changes section.
• KB Downloads and Release Notes (CPS: CEMR)
Monitor CQR Ingestion
Listen to our eleven-minute video on Monitoring Quality Reporting Data or reference our document (CPS, CEMR) on the same topic.
Assign / Confirm Source of Payment (SOP) codes for all insurance carriers 1. CMS requests data for all payers in MIPS submissions. The SOP code serves as a standard payer code across all submitters. 2. SOP codes were created by the Public Health Data Standards Consortium (PHDSC) and their Source of Payment Typology code set and Users Guide 7.0
may be used as guidance in assigning SOP codes. 3. Import and run our SOP report to confirm existing SOP assignments (CPS, CEMR). 4. Reference our GE SOP FAQ for more information.
o CPS: Mapping Source of Payment Codes o CEMR: Mapping Source of Payment Codes
Notes:
The registration fields required to assign SOP codes to insurance carriers or plans was introduced in CPS 12.0.7 and CEMR 9.8.7.
If on Service Pack 13 or higher, updated SOP codes will automatically resend patient data for impacted patients back to the first of the year.
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Research MIPS Explore CMS information at https://qpp.cms.gov/.
Explore the resources and education on the MIPS page of the GE Quality Reporting Community (CPS, CEMR).
Confirm Eligible Clinicians Search provider NPIs on the CMS QPP site to learn which of your providers need to submit data for MIPS.
Pick Your Pace for Participation*
*https://qpp.cms.gov/, April 13, 2017
Learn about MIPS
Research MIPS
Confirm Eligible Clinicians
Pick Your Pace for Participation
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To choose your measures in CQR, navigate to Configuration > Measurement Settings, and select a provider.
• If reporting for Medicaid, choose a Meaningful Use program. • If reporting for MIPS or CPC+, choose an ACI program. ACI Transition measures are available to use in 2017 and 2018 and utilize 2014 CEHRT.
Regular ACI measures are available beginning in 2018 and utilize 2015 CEHRT, which requires CPS 12.3 or CEMR 9.12.
ACI Performance and Bonus Measures • Explore CMS QPP page: https://qpp.cms.gov/measures/aci • Explore the resources and education on the MIPS page of the GE Quality Reporting Community (CPS, CEMR) . • Identify the documentation you’ll use for your audit file: (CPS, CEMR)
Quality Measures • Explore CMS QPP page: https://qpp.cms.gov/measures/quality • Explore the resources and education on the MIPS page of the GE Quality Reporting Community (CPS, CEMR) . • Use the Medicare FFS filter in CQR to ensure you have at least one Medicare Part B patient for one selected measure during your chosen reporting
period.
• Identify the documentation you’ll use for your audit file.
Improvement Activities • Explore CMS QPP page: https://qpp.cms.gov/measures/ia • Explore the resources and education on the MIPS page of the GE Quality Reporting Community (CPS, CEMR) .
• Identify the documentation you’ll use for your audit file: (CPS, CEMR)
Regularly monitor measures in CQR Regularly refresh calculations in CQR and work with your provider(s) to help them improve their results. The Quality Reporting Guide will provide
workflows and measure data requirements for meeting each measure. This user guide is located on our Quality Reporting Community and is updated
frequently so check back regularly for updates.
• CPS Quality Reporting Guide: PDF format or .chm Help File format
• CEMR Quality Reporting Guide: PDF format or .chm Help File format
Choose Measures
ACI Performance and Bonus Measures
Quality Measures
Improvement Activities
Regularly monitor measures in CQR
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Investigate and choose your MIPS submission method* 1. Choose your MIPS submission reporting option. GE supports the Electronic Health Record (EHR) Vendor reporting option and is the assumed reporting
method for this checklist. The measures available and the program requirements vary based on the reporting option chosen.
Note: If you are participating in a Medicare Accountable Care organization (ACO), your ACO is required to submit quality data to CMS on your behalf. We
only support CPS and CEMR data for submissions.
*CAPG Educational Series 2017: Quality Payment Program Webinars with CMS – How to Select Measures and Maximize Quality Performance in MIPS (5/5/17)
Choose Your Submission Method
Investigate and choose your MIPS submission method
If you choose the CMS Web Interface and/or CAHPS for MIPS survey, enroll with CMS by June 30, 2017
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2. Choose whether your clinicians will report as individuals or as a group.
• For 2017 reporting, CMS allows clinicians to report as an individual and in a MIPS Group. CMS will choose the submission with the higher score. If
you have a clinician enrolled in QSS that wants to send both individual and group submissions, refer to our QSS FAQ (CPS, CEMR) for more
information.
Note: GE will support both individual and group reporting for MIPS and CPC+. You may choose to enroll in GE’s Quality Submission Service (QSS) to have GE
submit your measure results to CMS on your behalf. QSS also offers additional features that may be required depending on the submission method(s) you
choose. Refer to our Quality Reporting Community for more information (CPS, CEMR), including our QSS FAQ (CPS, CEMR).
MIPS Individual Clinician
• Measure results are available on the MIPS and Dashboard tabs. • QRDA files for electronic submission will be available on the CQR Dashboard tab as of CQR v1.6. You may choose to enroll in GE’s Quality
Submission Service to have GE submit to CMS on your behalf.
MIPS Group (requires enrollment in QSS)
• Aggregated group measure results are available on the MIPS and Dashboard tabs. • Optionally, GE’s QSS will submit your results to CMS if you choose to authorize us to do so. Group QRDA files are not available to customers. • Review our MIPS and CPC+ 2017 Group Reporting FAQ (CPS, CEMR) for software requirements.
CPC+ (requires enrollment in QSS)
• Aggregated CPC+ site measure results are available on the MIPS and Dashboard tabs. • Optionally, GE’s QSS will submit your results to CMS if you choose to authorize us to do so. CPC+ site QRDA files are not available to customers.
CPC+ site configuration in QSS requires CPS 12.0 or CEMR 9.8 Service Pack 13 or higher. CPC+ requires registration and approval from CMS.
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If choosing to enroll in GE’s Quality Submission Service (QSS), follow the steps below. You may also refer to our QSS Enrollment Webinar.
Sign MQIC Agreement 1. If you have an existing MQIC# you can proceed to the next step. MQIC Agreements do not currently expire. If you have an existing agreement and you are
a Member or Program Admin role in CQR, you’ll see the following information, including your MQIC#, when you select the MQIC tab. If you don’t have access to the MQIC tab, refer to our MQIC FAQ for more information (CPS, CEMR) and sign the MQIC Agreement (CPS, CEMR).
Sign QSS Agreement in CQR 1. A Member or Program Admin role resource signs in to CQR and navigates to the MQIC > QSS tab. 2. Select the desired program (i.e. 2017 MIPS) and choose the Enroll button. 3. Enter organization and primary contact information. Primary contact email is used to send a link to the online QSS Agreement. 4. Select Send Agreement. An email from the docusign.net domain will be sent to the primary contact. A QSS Agreement must be signed electronically for
each organization. Follow Docusign workflow to review, sign and submit the agreement. You should receive an email from docusign.net stating “Your document has been completed.” Within three hours, your status should change to QSS Agreement Signed. You may then move to the next step.
5. Choose Complete Enrollment button.
Enroll Individual Clinician(s) 1. If submitting to CMS by individual clinician, enter the estimated number of eligible clinicians and select the reporting categories you want submitted via
QSS. You may create additional rows to break up your providers by the reporting categories they want to have submitted. Improvement Activities are only available if either ACI or Quality are also chosen. The purpose of this step is to estimate your requested services so that a QSS Order may be generated. You’ll select an actual reporting method per clinician later in the process. When complete, choose Save. Note: Billing will be based on actual clinicians submitted by GE. GE will submit for any clinician that you select to authorize in CQR.
If using QSS, Enroll: Automated Process in CQR
Sign MQIC Agreement (if you are not an existing member) and/or QSS Agreement Enroll individual clinician(s) and MIPS group(s) Include / Exclude clinician(s) from MIPS Group(s) Sign and return the QSS Contract Order to sales (requires manual submission) Enter/Validate provider information in CQR and request consent forms
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Enroll MIPS Group(s)
1. If submitting to CMS by group, please also reference our MIPS and CPC+ 2017 Group Reporting FAQ (CPS, CEMR). 2. There are a couple of preparation tasks for your CQR practices to address first. For each practice that you want to include in a MIPS Group, follow the
steps below. a. Add Practice Address and Tax ID. Navigate to Configuration > Organizational Structure. Find a practice, select the Edit icon, and enter the
Address and Tax Id if blank. Select Update. b. Note any practice that has a blank Location ID and follow our import practices instructions. EMR Locations of Care are connected to practices in
CQR using a Location ID, which allows CQR to properly link results. There are common scenarios where a Location ID is missing from the practice configuration. For any practice missing a Location ID that you want to include in a MIPS Group, you will need to first need to import it from your EMR. For instructions, search for (CTRL F) the Importing Practices (LOCs) from CPS/CEMR to CQR section of the CQR User Manual (CPS, CEMR).
3. Select MIPS Group Enrollment and Add MIPS Group. For each group, enter a Tax ID and desired performance categories to have submitted. CQR will
automatically list any Locations of Care associated with that Tax ID and will search for Encounter Orders (not Document Types) in 2017 to identify and count associated clinicians. Ideally, within the following two weeks, confirm the list of clinicians and include or exclude clinicians below as necessary. Note: Billing will be based on access to group reporting vs. submission. The QSS Order will be based on the groups created at the time the Order is processed, however, you will ultimately be invoiced based on the higher of either the count of clinicians when a group is created, including inactivated groups, or the count of clinicians submitted after you authorize.
4. For users to see the new MIPS Groups on the MIPS and Dashboard tabs they will need to be granted permissions.
Include / Exclude Clinicians 1. If per above, CQR selects clinicians that CMS agrees can be excluded, you can choose to exclude them using the Exclude Clinician button. Use the CMS
MIPS participation lookup tool to confirm: https://qpp.cms.gov/participation-lookup. Excluded clinicians will not be billed for QSS participation.
2. You may also add clinicians that CQR did not identify. This may be because you use Document Types vs. Encounter Orders in some scenarios. It may also
be based on when you implemented CPS 12.0.13 or CEMR 9.8.13, as that is when we improved upon the scenarios where we send LOC to CQR.
Sign and return the QSS Contract (a.k.a. Order) to sales 1. The QSS primary contact will receive a QSS contract via email after at least two weeks for the number of estimated clinicians enrolled. 2. Sign the contract and follow instructions on the contract to send it back to GE sales.
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Enter / Validate provider information in CQR and request consent forms 1. Enter or validate each provider’s NPI, TIN, email address, and name.
• NPI and TIN numbers are required for submissions to CMS. CMS only accepts one submission per NPI/TIN combination. A provider's NPI will import from the EMR into CQR, but the TIN must be manually entered. For group reporting, each individual provider's TIN must be identical to the group TIN to be included in the group calculations.
• Email addresses in CQR are used to send electronic consent forms to the participating providers to sign. Email addresses are not populated by your EMR.
• Provider names are imported from your EMR. In many cases, the provider’s credentials are included in their last name. When you request a Consent Form for any provider, our online form vendor, Docusign, uses an electronic signature that consists of the provider’s initials that are based on the first letter in the first and last name fields in the CQR provider name fields plus the first letter follow a space. For instance, Joe Jones M.D., where first name is Joe and last name is Jones M.D., Docusign would use the initials of JJM. For any provider that would not agree to such initials should have their credentials removed from their last name field in CQR prior to requesting a Consent Form.
On the MQIC tab, each provider will show a message if additional information is required (i.e. Missing NPI). For each provider that plans to participate in
QSS but shows as needing information, select an individual or group of providers and click Update Selected Providers.
2. Choose the Send consent form button. Once a provider’s consent form is signed, nothing should show to the right of the provider’s name. With the change to MIPS, even providers that signed a consent form in previous years must sign a new consent form. Possible Consent Form Statuses: Send – Consent form has not been sent Blank – NPI, TIN, or email address is blank Completed – provider has signed the consent form Pending – the consent form has been emailed but has not been signed and submitted Expired – 30 days has passed with no signature since a request was sent Rejected – clinician declined signing the consent form Undeliverable – the request could not reach the intended recipient mailbox (invalid email address)
Note: For additional information on any of the above processes please reference our CQR User Manual (CPS, CEMR).
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Select Measures and Authorize Provider(s) and/or Group Instructions for 2017 MIPS authorization not yet available. They will be updated prior to the forecasted open date of January 10, 2018.
Confirm completion of authorizations When you are finished selecting measures for all clinicians and completed all authorizations, scroll down to the Confirm Completion of Authorization section and select the check box for Authorization of clinicians and groups. Selecting this confirmation check box: • Indicates that authorizations are complete for the entire organization and GE Healthcare can begin submissions to CMS. • Prevents additional providers from being added for authorization. • Displays the MQIC tab and Provider List in "View Only" mode. • Still allows you to click the hyperlink, "View Authorization".
Receive confirmation email from GE Healthcare and validate provider list GE will send a confirmation email to the QSS primary contact specified during QSS enrollment. This email will include a list of clinicians or groups that GE
submitted MIPS data to CMS for, a CMS batch number that CMS provided to GE as confirmation of receipt of the file, and the submission status of either
success or rejection.
• Confirm that the list of clinicians contained in the confirmation email match the clinicians you authorized. If any clinician(s) or group(s) have a rejected status, you should have been notified by GE of the rejection in advance of the confirmation email.
• Call GE support or your Value-Added Reseller if you have questions on the confirmation email or if you disagree with the information provided prior to March 16, 2018 to allow time for GE to resubmit data prior to the CMS reporting deadline if that is necessary.
• Keep the confirmation email and clinician list in your audit file for future reference.
If using QSS, Authorize Submission
Select measures and Authorize provider(s) and/or group Confirm completion of authorizations Receive confirmation email from GE Healthcare and validate provider list
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Document Changes
May 18, 2017 Initial version May 22, 2017 Added 2016 MU Hardship deadlines of July 1st and Oct 1st 2017 June 1, 2017 Added link to 2017 Software Requirements document June 29, 2017 Added information on assigning SOP codes August 22, 2017 Added enrollment and authorization dates.
Added note regarding proposed rule next to 12.3/9.12 requirement for 2018. September 21, 2017 Updated information on Knowledgebases, including 2017 value sets.
Added a note regarding timing of installing CQR. Added link to SOP Report. Added link to CMS audit file documentation suggestions. Added User Manual link to QSS group enrollment section for import practices instructions Updated QSS Enrollment instructions (still subject to change prior to enrollment opening in October).
October 4, 2017 Updated checklist to reflect that 2016 PQRS QRUR reports were sent to providers by CMS in September and appeals are due by December 1st, 2017.
October 23, 2017 Added MQIC Agreement as task. Updated QSS enrollment instructions for 2017 MIPS. Removed 2016 authorization instructions. Authorization open data re-forecasted to be January 10th
November 20, 2017 Added QSS MIPS Group CPS 12.0.13 or CEMR 9.8.12 requirement. January 4, 2018 Removed requirement to install 2015 CEHRT based on QPP Final Rule that allows 2014 or 2015 CEHRT in
2018. Changed MIPS Group requirements to reference Group Reporting FAQ. Add CQR Navigation to Choosing Measures section. Updated Choose Your Submission Method section.
January 9, 2018 Authorization process start is now January 17th. In CQR 1.6, all three performance categories (ACI, Quality, and Improvement Activities) will be available in individual provider QRDAs on dashboard tab.
