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Andrew Montalvo · Feb 7, 2022

Traditional MIPS program: What’s required for 2022?

You may have heard that the Merit-based Incentive Payment System (MIPS)—called “Traditional MIPS”—will be fading into the sunset by 2027.

In 2022, there will be significant changes to the existing Traditional MIPS program in preparation for CMS’ move toward two new “Pathways” programs that will ultimately replace Traditional MIPS. In the coming weeks, look out for more blog posts detailing CMS’ efforts to continually enhance value and quality in patient care with the MIPS Value Pathways (MVPs) and the Alternative Payment Model Performance Pathway (APP).

This article will help familiarize you with the changes coming to Traditional MIPS in 2022 and help prepare you for the upcoming transition to MVPs.

Traditional MIPS: changed reporting requirements

Established in the first year of the Centers for Medicare and Medicaid (CMS)’s Quality Payment Program (QPP), Traditional MIPS is the initial framework that currently remains available to MIPS-eligible providers for obtaining and reporting performance data measures across four areas:

  • Promoting Interoperability (PI)
  • Quality
  • Improvement Activities
  • Cost

MIPS-eligible clinicians will be able to use the Traditional MIPS framework until they choose or are required to use the new APP (available in 2022) or the new MVP framework (available beginning in 2023).

General changes

Two New Provider Types are now considered MIPS-eligible clinicians:

  • Clinical social workers
  • Certified nurse-midwives

Why this is important:

  1. CMS proposed these additions to align with the Alternative Payment Model (APM)’s eligible clinicians’ definition. An eligible clinician (EC) is one who is eligible to participate in the QPP through MIPS or other CMS programs using electronic clinical quality measures (eCQMs) for quality reporting, such as APM participants.
  2. If your practice’s providers include clinical social workers and/or certified nurse-midwives, they will need to establish new provider workflows to capture the necessary data elements required by MIPS. The Practice Fusion EHR will be equipped to help you initiate MIPS reporting for these new provider types.

Clinical social workers’ MIPS considerations

Although clinical social workers were not required to report on MIPS in the 2020 and 2021 PPs, CMS did introduce a finalized Clinical Social Work MIPS Specialty Measure Set for 2021 to help these providers prepare for when they would be added to the listing of MIPS-eligible clinicians in future rule-making—that is, for the performance year 2022.

What are the specific Quality measures in the Social Work MIPS Specialty Measure Set? CMS is expected to finalize the approved Quality Measures for the Social Work Specialty Measure Set in early 2022. Therefore, some of the measures approved for 2022 may differ slightly from those finalized for 2021. The finalized 2021 Measure Set includes the following:

  • Two Quality measures from the originally required Quality measures:
  1. Documentation of Current Medications in the Medical Record
  2. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • Several Quality measures that are more specific to the Social Work Specialty, such as the following (though not an all-inclusive list):
  1. Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  2. Elder Maltreatment Screen and Follow-Up Plan
  3. Dementia: Cognitive Assessment
  4. Dementia: Functional Status Assessment
  5. Dementia: Education and Support of Caregivers for Patients with Dementia
  6. Depression Remission at 12 Months (outcome measure)
  7. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (intermediate outcomes measures)

Click here for a full listing of all Quality measures within the Social Work MIPS Specialty Measure Set and data requirements for each.

Clinical social workers and Promoting Interoperability MIPS requirements

As noted above, fulfilling MIPS includes four different categories, one of which is the Promoting Interoperability (PI) category. CMS has indicated that clinical social workers* may automatically reweight their PI score to zero and distribute their total MIPS scoring per the following:

  • Quality: Increases from 30% to 40%
  • Cost: Remains at 30%
  • Improvement Activities: Increases from 15% to 30%
  • *Automatic reweighting is also provided for clinicians who belong to small practices, defined as those with 15 or fewer MIPS-eligible clinicians who bill under the practice’s Tax ID Number (TIN).

Certified nurse-midwives’ MIPS considerations

Certified nurse-midwives (CNMs) are advanced practice registered nurses (APRNs) who also have certification as midwives. Because they are APRNs, they can prescribe medications and have more clinical responsibilities than registered nurses (RNs).

CMS does not currently provide a Clinical Quality Measure Set for CNMs. Therefore, they are required to report six separate quality measures from the list of Clinical Quality Measures (CQMs), including general quality measures and any available measures related to their specialty. Unlike clinical social workers, CNMs may not reweight their PI scores to zero.

Changes in overall MIPS scoring

By category: Beginning with the 2022 PP, the QPP program is required by law to equally weigh the Quality and Cost categories at 30% each. The PI and Improvement Activity (IA) categories remain at the same percentages as in CY 2021: 25% and 15%, respectively. (As noted above, an exception is made for small practices and clinical social workers whose PI categories are weighted to zero.)

Performance thresholds Beginning in 2022, ECs must reach a Minimum Performance Threshold of 75 total MIPS points—up from 60 MIPS points in 2021.

A score of 75 points was the mean final score in the CY 2017 PP (2019 payment year). This fulfills the requirements for CMS, where for 2022, ECs must establish a performance threshold that is the medium or mean of all EC’s final MIPS scores for an earlier PP.

Further, to receive the Exceptional Performance bonus for 2022 performance, MIPS-eligible clinicians will need to receive a score of >89 points. CY 2022 is the last year for participating providers to receive an Exceptional Performance bonus.

Starting in 2023, just penalty fees will fund the program. As the program requirements become more difficult, it’s expected that more clinicians may be affected by negative payment adjustments.

Promoting Interoperability category

For the performance year 2022, there are new reporting requirements for Traditional MIPS in addition to the PI requirements for 2021.

Public health and clinical data exchange

In CMS’ commitment to supporting public health agencies in their long-term COVID-19 recovery and in the face of possible future health threats:

  • CMS will now require that ECs report to the Immunization Registry and Electronic Case Reporting (unless they can take an appropriate exclusion). Note that CMS has also added a fourth exclusion to the Electronic Case Reporting for 2022 only: i.e., “Uses certified electronic health record technology (CEHRT) that isn’t certified to the electronic case reporting certification criteria prior to the beginning of the performance period they select for 2022.”
  • The Clinical Data Registry, Public Health Registry, and Syndromic Surveillance Reporting are now optional. MIPS-eligible clinicians will receive a 5-point bonus if they attest with a “Yes” response to any of the three registries. (However, attesting “Yes” to two or three of the registries will not add more than the initial 5-point bonus.)

New required measure: SAFER Guides, also known as the “Safety Assurance Factors for EHR Resilience Guides”

This new measure requires that MIPS-eligible clinicians attest to performing an annual assessment of the SAFER Guides beginning with the 2022 MIPS performance year. The purpose of the guides is to provide best practices to help optimize the safety and safe use of EHRs. The guides are divided into three broad groups, including Foundational Guides, Infrastructure Guides, and Clinical Process Guides.

Requirement for the “Provide Patients Electronic Access to Their Health Information” requirement

Patients must be provided timely access to view online, download, or transmit their health information indefinitely for encounters on or after January 1, 2016.

Improvement Activities category

In the 2022 performance year, CMS is retaining:

  • The same weight for the IA performance score at 15% of the total MIPS score.
  • Selection of medium- and high-weighted activities to fulfill the IA score.
  • The 90-day minimum performance period

New, modified, and retired Improvement Activities for CY 2022

  • CMS has added seven new IAs, including three new health equity measures.
  • CMS has modified 15 IAs, where 11 of the activities address health equity measures—and some add new requirements specifically addressing racial equity issues.
  • CMS has removed six previous IAs.

CMS continues its strategic commitment to driving innovation to promote healthcare equity and access to high-quality, patient-centered care in 2022. Such commitment is demonstrated by the many changes to the IAs to address equity issues as well as its extension of telehealth services, the use of audio visits, increased access to physicians’ assistants through billing changes, and other measures.

Click here for a complete listing of 2021 MIPS Improvement Activities. Select the “Improvement Activities” tab and click on the “2021 Improvement Activities Inventory.” (Although the 2022 MIPS IA list hasn’t yet been released by CMS, we will provide that link when it’s available. )

New policy to cease Improvement Activities as appropriate

In 2022, CMS is also implementing a policy to immediately stop IAs if there is reason to suspect that the activity presents potential patient safety issues or is obsolete. CMS will promptly stop the IA and notify providers and the public through CMS web postings and listservs. They will also propose removing or modifying the IA as needed in the following rulemaking cycle.

Process for nominating new Improvement Activities for CY 2022

CMS has introduced two new criteria for nominating new IAs: (1) The IA should not duplicate other IAs. (2) The IA should drive improvements that extend beyond standard clinical practice. Some practices may fulfill the IA category by continuing to conduct existing procedures and services, yet the intent is to introduce new patient-centered activities that will further enhance quality of care and patient outcomes, CMS has also proposed that new IAs must fulfill six existing criteria and consider six new optional measures for nominated activities.

Cost category in 2022

For the year 2021, CMS used cost measures that evaluated the following:

  • Total per-capita costs (TPCC) given to Medicare patients, focusing on Primary Care
  • Medicare spending per beneficiary (MSPB) clinician
  • The cost of services and items provided during 18 episodes of care for Medicare patients

Although CMS did not add any new episode-based cost measures in 2021, it added telehealth visits to the cost measure calculations if applicable. CMS categorized the 18 episode-based cost measures into episode groups, including procedural episodes or acute inpatient episodes.

In addition, for 2022, CMS added five new episode-based measures, including two measures in a new category for chronic conditions.

Quality category in 2022

Beginning in 2022, CMS is proposing multiple changes to the Traditional MIPS Quality measure scoring to align and obtain consistency with CMS proposals for scoring the new MIPS Value Pathways (MVPs). CMS will introduce the MVPs gradually beginning in the 2023 performance year to provide clinicians, EHR vendors, payers, and other third-parties sufficient time to prepare.

Due to COVID-19, CMS will use a different baseline period

In 2022, the reporting period for Quality will continue to be the full calendar year. However, due to the uncontrollable and extreme circumstances resulting from the COVID-19 public health emergency (PHE), CMS is proposing the use of a different baseline period as performance period benchmarks, such as the calendar year 2019, pending assessment of the 2020 PP data.

Scoring updates to the Quality performance category

Beginning in 2022, there are several scoring changes for the Quality category:

New Quality measures For new Quality measures, if no performance benchmark can be established, the measure will earn 7 points in the first PP and 5 points in the second PP—i.e., if data completeness and case minimum criteria are met (see below).

Quality measure case minimum requirements The case minimum criterion for reporting Quality measures is at least 20 patient cases, regardless of payer.

Quality measure data completeness requirements MIPS-eligible clinicians must report at least 70% of eligible patient cases for every Quality measure for the 2022 performance period.

When Quality benchmarks are in place In 2021 and in prior years, there was a 3-point floor for Quality measures that could be scored against a benchmark. However, for measures with a benchmark, CMS is now proposing that the 3-point floor be removed, and such measures may receive a score of 1 to 10 points depending on performance.

When Quality benchmarks are not in place Previously, Quality measures that did not yet have a historical or PP benchmark earned 3 points. Yet CMS is now proposing that the 3-point floor be removed, and the measures will receive 0 points. However, this does not apply to small practices, which will continue to obtain 3 points.

When the Quality measure required if case minimum is not met In the 2021 performance period, if Quality measures did not meet the required case minimum (i.e., 20 cases), they received 3 points. However, CMS is now proposing that if measures do not meet the case minimum, the 3-point floor is removed. (Again, this does not apply to small practices, which will continue to earn 3 points.)

New, modified, and retired Quality Measures for CY 2022

Approximately 200 Quality measures are available for reporting for the 2022 performance period, including significant changes to over 80 existing Quality measures; one new specialty measure set for certified nurse-midwives; four new Quality measures; and removal of 15 Quality measures. As of 2021, 17 Electronic Clinical Quality Measures (eCQMs) are available in Practice Fusion for reporting quality measures.

Postponed retirement of the CMS Web Interface

Although CMS proposed retiring its Web Interface for Traditional MIPS reporting for the 2022 performance year, this resulted in significant concern and pushback by Accountable Care Organizations (ACOs).

In response, CMS recognized such concerns and is now proposing extending the availability of the CMS Web Interface, which relies on Medicare beneficiary data, as a collection and submission type for Traditional MIPS for registered and virtual groups and APMs with >25 clinicians through the 2022 performance year.

Importantly, CMS now proposes sunsetting its Web Interface for Traditional MIPS reporting with the 2023 performance year. CMS will retire the Web Interface for ACOs after the 2024 performance year.

A note on ACOs

If your ambulatory practice is a member of an ACO that participates in the Medicare Shared Savings Program (MSSP), be aware that ACOs will be required to report on eCQMs or MIPS CQMs for all payers (i.e., not solely Medicare patients) under the new APM Performance Pathway. (An eCQM is calculated electronically by a CEHRT, whereas a CQM can be calculated outside of a CEHRT, such as via manual chart abstraction.)

For the 2022 performance year, ACOs will be able to choose between reporting all-payer clinical quality measures or continuing to report on a sample of Medicare patients via the CMS Web Interface.

ACOs will still have the option to use the CMS Web Interface in 2023, but they will also be required to report on one all-payer quality measure. The APP requires that ACOs either use a CEHRT to capture eCQMs or engage with a CMS-qualified registry that supports MIPS CQMs. Both reporting methods assess quality performance based on all-payer data.