Skip to main content

January 2022 Quest Details

Top

MIPS 2021 Data Submission Period Is Now Open

To sign in and submit data, clinicians will need to register in the Health Care Quality Information Systems (HCQIS) Authorization Roles and Profile (HARP) system. For clinicians who need help enrolling with HARP, please refer to the Quality Payment Program (QPP) Access User Guide (ZIP). 

Note: Clinicians who are not sure if they are eligible to participate in the QPP can check their final eligibility status using the QPP Participation Status Tool. Clinicians and groups that are opt-in eligible will need to make an election before they can submit data. (No election is required for those who do not want to participate in the Merit-based Incentive Payment System [MIPS].)

If you are in a small practice (15 or fewer clinicians) and need help from our Small, Underserved, and Rural Support (SURS) technical assistance organizations to submit your data, we encourage you to reach out early in the data submission period. The SURS initiative will be ending on February 15, 2022 and this support will no longer be available after that date.

For More Information

To learn more about how to submit data, please review the following resources available on the QPP Resource Library:

Additional resources will be posted to the Resource Library later this month. You may also contact the QPP at 1.866.288.8292 or by email at: QPP@cms.hhs.gov.

QPP Service Center Hold Times Expected to Increase

The Quality Payment Program (QPP) Service Center is projecting an increase in volume of calls and emails between January and March 2022 due to the opening of 2021 MIPS data submission period. The increase in call volume and emails will result in longer wait times.

In order to reduce wait times and ensure successful 2021 submission, CMS recommends taking the following actions:

  • Use One Method to Report Issues—Due to the increase in volume at the QPP Service Center and to minimize backlog, CMS requests that you use only one method of reporting for the same issue (email or phone). Note: Cases are processed in the order in which they are received regardless of the manner in which the Service Center was contacted. Please allow time for processing.
  • Submit Your Data Early—It is encouraged that you submit your 2021 MIPS performance year data early during the submission period as this allows you plenty of time for any necessary Service Center assistance.
  • Call the Service Center at Off-Peak Hours—CMS strongly recommends calling the Service Center during off-peak hours (8:00 AM-10:00 a.m. ET OR 2:00 p.m.-8:00 p.m. ET).

For More Information

  • Visit the QPP Resource Library to review new and existing QPP resources.
  • Contact the QPP at 1.866.288.8292 or by email at: QPP@cms.hhs.gov.
    • Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

QPP Participation Status Tool Now Includes Third Snapshot of 2021 Qualifying APM Participant and MIPS APMs Data

The third snapshot includes data from Medicare Part B claims with dates of service between January 1, 2021 and August 31, 2021. The tool includes 2021 Qualifying APM Participant (QP) and Merit-based Incentive Payment System (MIPS) APM participation status.

To learn more about how CMS determines QP and APM participation status for each snapshot, please view the 2021 Learning Resources for QP Status and APM Incentive (ZIP) or visit the Advanced APMs webpage on the QPP website.

What Does QP Status Mean?

If you qualify as a QP, this means you are:

  • Eligible for the 5% APM incentive bonus; and
  • Exempt from participating in MIPS.

How Do I Check My QP or APM Participation Status?

To view your QP or APM participation status at the individual level:

To check the eligibility status of the clinicians in your APM entity:

  • Log into the CMS QPP website. Learn how by downloading the QPP Access User Guide (PDF).
  • Browse to the Taxpayer Identification Number(s) affiliated with your entity.
  • Access the details screen to view the eligibility status of every clinician based on their NPI.

If you qualify as a Partial QP, you will be able to choose whether or not you want to participate in MIPS, but you will not be eligible for the 5% incentive payment. To learn more, please view the 2021 QP Quick Start Guide.

Learn More

For more information on APMs, visit the QPP APM webpages. For a comprehensive list of APMs and additional materials, visit the QPP Resource Library.

Questions?

Contact the QPP at 1.866.288.8292 or by email at: QPP@cms.hhs.gov. To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.

  • Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

CMS Approves Performance Period Truncation of the 2021 Performance Period for Quality Measure #111: Pneumococcal Vaccination Status for Older Adults MIPS CQM, Medicare Part B Claims, and eCQM Collection Types to the First 9 Months of Data

CMS will truncate the performance period to the first 9 months of data for the Medicare Part B claims, MIPS clinical quality measure (CQM), and electronic clinical quality measure (eCQM) collection types for measure Q111: Pneumococcal Vaccination Status for Older Adults.

At the October 20, 2021 meeting, the Advisory Committee on Immunization Practices (ACIP) approved, by majority vote, to update the pneumococcal vaccine recommendations. The revised recommendation no longer aligns with the current posted measure specifications for the Medicare Part B claims, MIPS CQM, and eCQM collection types, as numerator compliance is achieved through administration or previous receipt of either the pneumococcal conjugate vaccine (PCV) 13 or pneumococcal polysaccharide vaccine (PPSV23) vaccine (or both).

ACIP now recommends:

  • Adults ages 65 and older with no previous receipt of or unknown status of vaccination should receive the PCV20 or PCV15 vaccine.
    • If PCV15 is administered, this should be followed by a dose of PPSV23.
  • Adults ages 19–64 with certain underlying conditions of risk-factors with no previous receipt of or unknown status of vaccination should receive the PCV20 or PCV15 vaccine.
    • If PCV15 is administered, this should be followed by a dose of PPSV23.

Therefore, CMS is truncating the performance period for the Medicare Part B claims, MIPS CQM, and eCQM collection types for this measure to the first 9 months of data in accordance with § 414.1380(b)(1)(vii)(A). MIPS-eligible clinicians do not need to submit any additional documentation, and CMS will assess the measure for these collection types based upon the first 9 months of data. 

2021 Performance Period Suppressed MIPS Quality Measures

Policies on Suppressing Certain Quality Measures

The following measures are excluded from a MIPS-eligible clinician’s total measure achievement points and total available measure achievement points:

(i) each submitted CMS Web Interface-based measure that meets the data completeness requirement, but does not have a benchmark or meet the case minimum requirement, or is redesignated as pay-for-reporting for all Shared Savings Program accountable care organizations by the Shared Savings Program; and

(ii) each administrative claims-based measure that does not have a benchmark or meet the case minimum requirement. 42 C.F.R. § 414.1380(b)(1)(i)(A)(2).

Beginning with the 2019 MIPS performance period, for each measure that a MIPS-eligible clinician submits that is significantly impacted by clinical guideline changes or other changes that CMS believes may result in patient harm or misleading results, the total available measure achievement points are reduced by 10 points. 42 C.F.R. § 414.1380(b)(1)(vii)(A).

Quality Measure Number/Title Collection Type Impacted Suppression Rationale

Measure 001:
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Medicare Part B Claims

Quality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (3051F and 3052F) that were not activated during the annual Current Procedural Terminology (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with § 414.1380(b)(1)(vii)(A).

Measure 111:
Pneumococcal Vaccination Status for Older Adults

Medicare Part B Claims

MIPS Clinical Quality Measure (CQM)

Electronic Clinical Quality Measure (eCQM)

Updated Guidelines: Guidelines have been revised to allow 20-valent pneumococcal conjugate vaccine by itself or the 15-valent vaccine followed by the 23-valent vaccine for adults ages 65 years or older who have not received a pneumococcal conjugate vaccine before—or whose vaccination status is unknown—and people ages 19 to 64 years who have an underlying medical condition or other risk factors and who also have not received a pneumococcal vaccine.

Truncation Rationale: Due to the updated guidelines allowing the use of 15—or 20-valent pneumococcal conjugate vaccine, this measure will likely produce misleading results for the last quarter of the performance period. The current measure specifies that only PCV13 or PPSV23 vaccine (or both) will meet the quality action. Therefore, this measure will be truncated to the first 9 months of the performance period for the Medicare Part B claims and MIPS CQM collection types in accordance with § 414.1380(b)(1)(vii)(A).

Measure 117:
Diabetes: Eye Exam
Medicare Part B Claims

Quality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (2023F, 2025F, and 2033F) that were not activated during the annual Current Procedural Terminology (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).

Measure 128:
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
eCQM

Quality Measure Implementation Resulting in Misleading Result: During the 2021 performance period, a misalignment was identified between the numerator header in the measure narrative and the numerator logic. Due to a change in the CQL, the timing for documenting the quality action changed and, according to the CQL definition, may in some circumstances extend beyond the end of the measurement period. Clinicians, groups, and/or virtual groups may submit data per the defined time except when the quality action takes place beyond the end of the performance period.

Suppression Rationale: Due to the inability to accurately submit the quality action and the misalignment between the measure narrative and logic, CMS determined that this measure has undergone a significant change that may result in misleading results. Due to the logic revisions, clinicians, groups, and/or virtual groups will not receive credit for a follow-up plan documented in PY2022 and would fail the measure because reporting would show as no follow-up documented. Therefore, this measure will be suppressed within the eCQM collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).

Measure 134:
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS Web Interface

Quality Measure Implementation Resulting in Misleading Results: CMS determined that coding changes made to the 2021 PREV-12 were substantive changes to the measure. 

The modifications removed the Systematized Nomenclature of Medicine (SNOMED) codes that recognized the rescreening of a patient using an additional standardized depression screening tool as a means of meeting the performance criteria for implementing an appropriate follow-up plan specific to a patient with a positive depression screening.

Suppression Rationale: The coding changes no longer allow clinicians to meet the performance criteria of implementing a follow-up plan without providing an appropriate follow-up plan to the patient (patient would not be eligible for the measure numerator). For the 2021 performance period, the following will apply to the PREV-12 measure:

Excluded from the Merit-based Incentive Payment System (MIPS) scoring in accordance with §414.1380(b)(1)(i)(A)(2)(i) provided that the measure meets the data completeness requirement and the data applicable to the measure is reported via the CMS Web Interface.

CQL = Clinical Quality Language; PY = Performance Year

Contact the QPP at 1.866.288.8292 or by email at: QPP@cms.hhs.gov (Monday-Friday 8 a.m.–8 p.m. Eastern Time [ET]). To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.

  • Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

CMS Is Soliciting Stakeholder Recommendations for Potential Consideration of New Specialty Measure Sets and/or Revisions to the Existing Specialty Measure Sets for the 2023 Performance Year of the MIPS 

CMS is accepting stakeholders’ recommendations regarding potential new specialty measure sets and/or revisions to existing specialty measure sets for the 2023 performance year of MIPS. Recommendations for new specialty sets or revisions to the 2022 specialty sets should be based on the established 2022 MIPS quality measures. Visit the QPP Resource Library to view the 2022 MIPS quality measure specifications. CMS specifically requests stakeholder feedback on applicable quality measures for the following specialty: Optometry.

In addition, specialty set recommendations may be accepted based on potential new MIPS quality measures that are being considered for implementation in the 2023 performance year. These potential MIPS quality measures can be found on the 2021 Measures Under Consideration (MUC) List (PDF).

The current 2022 specialty measure sets are located in the Appendix measure tables of the calendar year (CY) 2022 QPP Final Rule, with the comment period located on the QPP Resource Library.

As established in the CY 2022 QPP Final Rule, specialty measure sets currently exist for the following specialties:

  • Allergy/Immunology
  • Anesthesiology
  • Audiology
  • Cardiology
  • Certified Nurse Midwife
  • Chiropractic Medicine
  • Clinical Social Work
  • Dentistry
  • Dermatology
  • Diagnostic Radiology
  • Electrophysiology Cardiac Specialist (a subspecialty of Cardiology)
  • Emergency Medicine
  • Endocrinology
  • Family Medicine
  • Gastroenterology
  • General Surgery
  • Geriatrics
  • Hospitalists
  • Infectious Disease
  • Internal Medicine
  • Interventional Radiology
  • Mental/Behavioral Health
  • Nephrology
  • Neurology
  • Neurosurgical
  • Nutrition/Dietician
  • Obstetrics/Gynecology
  • Oncology/Hematology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Pathology
  • Pediatrics
  • Physical Medicine
  • Physical Therapy/Occupational Therapy
  • Plastic Surgery
  • Podiatry
  • Preventive Medicine
  • Pulmonology
  • Radiation Oncology
  • Rheumatology
  • Skilled Nursing Facility
  • Speech Language Pathology
  • Thoracic Surgery
  • Urgent Care
  • Urology
  • Vascular Surgery

Each recommendation must include the following in order to be considered:

  • Quality measure identifier (ID)
  • Measure title
  • Rationale and/or documentation that supports inclusion or exclusion of the current quality measure(s) from existing specialty measure sets or inclusion in new specialty measure sets

Submissions of recommendations for a new specialty measure set and/or revisions to the current 2022 specialty measure sets should be sent to the Practice Improvement and Measures Management Support (PIMMS) Quality Measures Support mailbox at PIMMSQualityMeasuresSupport@gdit.com.

Submissions of recommendations will be accepted from stakeholders up until close of business on Monday, February 14, 2022.

All recommendations submitted by the aforementioned deadline will be considered and assessed for possible inclusion in rulemaking for the 2023 performance year of the QPP.

Note: Submissions of recommendations for new specialty measure sets, and/or revisions to the current 2022 specialty measure sets, does not guarantee that the recommendation will be accepted, proposed, or finalized during rulemaking for the 2023 performance year of the QPP. Determinations as to whether recommendations are accepted will not be communicated with stakeholders directly, since they are being considered for the 2023 performance year, but will be made evident through publications of the CY 2023 Quality Payment Program Proposed and Final Rule.