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Kick Off December 12, 2018 Disclaimer This presentation was - - PowerPoint PPT Presentation

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2018 CMS Web Interface Quality Reporting for MIPS Groups and ACOs CMS Web Interface Kick Off December 12, 2018 Disclaimer This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently,

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2018 CMS Web Interface Quality Reporting for MIPS Groups and ACOs

CMS Web Interface Kick Off

December 12, 2018

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Disclaimer

This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently, so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

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Announcements

  • CMS Web Interface resources are now available on Quality Payment Program

Resource Library:

  • 2018 CMS Web Interface Excel Template
  • 2018 CMS Web Interface Excel Template User Guide
  • 2018 CMS Web Interface Excel Template with Sample Data
  • 2018 CMS Web Interface Excel to XML Mapping
  • 2018 CMS Web Interface Data Dictionary (rev. 12/10/2018)
  • 2018 CMS Web Interface FAQs
  • CMS Web Interface webinar materials are now available on Quality Payment

Program Webinar Library:

  • CMS Web Interface User Demonstration (11/14/2018)
  • Recording, slides, transcript

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New Web Interface Resources

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Reminders

  • CMS Web Interface Application Programming Interface (API) Trial Period

(September 11, 2018 – January 4, 2019)

  • API Trial Period in Production Preview
  • Log into the CMS API production preview environment.
  • Use the API to programmatically retrieve a production-like beneficiary sample, map

it to your electronic health record (EHR) data, and submit your responses for end- to-end testing.

  • For more information, please review the following:
  • 2018 CMS Web Interface API Narrative Documents

https://cmsgov.github.io/beneficiary-reporting-api-docs/

  • Swagger Documents

https://qpp.cms.gov/api/preview/submissions/web-interface/docs

  • For direct support, please refer to the CMS Web Interface Google Group:
  • Developer Group for CMS Web Interface API (Google Group)

https://groups.google.com/forum/#!forum/cms-web-interface

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CMS Web Interface Key Dates

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Reminders

  • CMS Web Interface Test Period (January 7, 2019 – January 18, 2019)
  • Test Period: Download Your Sample & Test Mode
  • Log into the CMS Web Interface in test mode.
  • Download your sample.
  • Review your sample.
  • Work on filling in your data in the Excel template offline.
  • Upload your data to test out the CMS Web Interface.
  • Manually enter data by beneficiary or by measure into the CMS Web

Interface.

  • Review the Data Confirmation, Measure Rates, Data Irregularities, and

Activity Log Reports.

  • Use the Web Interface API to programmatically retrieve your beneficiary

sample, map it to your EHR data, and submit your responses for end-to- end testing.

  • NOTE: Any test data you upload or enter will be removed at the close of

the test period.

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CMS Web Interface Key Dates

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Reminders

  • CMS Web Interface Submission Period (January 22, 2019 - March 22, 2019)
  • Submission Period
  • The CMS Web Interface closes promptly at 7:59pm Eastern Daylight

Time (EDT) on March 22, 2019.

  • The CMS Web Interface will automatically accept your submission at

the end of the submission period.

  • Accessible via the “Sign In” link on the Quality Payment Program

website at https://qpp.cms.gov.

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CMS Web Interface Key Dates

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Reminders

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Upcoming CMS Web Interface Webinars

  • Weekly Support Webinars
  • Please note: All weekly support webinars listed below will be held on

Wednesdays from 1:00PM to 2:00pm EST/*EDT. January 9, 2019 February 20, 2019 January 16, 2019 February 27, 2019 January 23, 2019 March 6, 2019 January 30, 2019 March 13, 2019* February 6, 2019 March 20, 2019* February 13, 2019

  • For more information on the webinars and links to register, review 2018 CMS Web

Interface Support Webinars flyer.

  • If you encounter any issues with registration or audio issues with your

computer during a webinar, please send an e-mail to CMSQualityTeam@Ketchum.com.

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REPORTING REQUIREMENTS

Presenter: Sandra Adams, CMS

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Reporting Requirements

  • Organizations must completely report quality data on the required number of

beneficiaries in order to satisfactorily report:

  • Minimum of 248 consecutively confirmed and completed beneficiaries for each measure;

OR

  • 100 percent of beneficiaries if there are fewer than 248 beneficiaries available in the

sample.

  • Avoiding the 2020 MIPS downward payment adjustment
  • Complete reporting of all 15 CMS Web Interface quality measures will meet

requirements for the quality performance category, for the 2018 performance year.

  • MIPS groups and eligible clinicians participating in an ACO must meet MIPS reporting

requirements for all performance categories to avoid the downward adjustment.

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Reporting Requirements

  • Shared Savings Program/Next Generation: ACOs who fail to satisfactorily report all

measures will not meet the quality performance standard and will be ineligible to share in savings, if earned.

  • TINs who participate in a Shared Savings Program ACO that fails to satisfactorily report

the CMS Web Interface measures and CAHPS for ACOs will get a MIPS quality performance score of zero unless they report separately from the ACO either as a group

  • r solo practitioner TIN.
  • For details regarding the interactions between the Shared Savings Program and MIPS

please review the guide available on the Quality Payment Program Resource Library: 2018 Medicare Shared Savings Program & MIPS Interactions.

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ENTERPRISE IDENTITY DATA MANAGEMENT (EIDM) RESOURCES

Presenter: Chris Reinartz, CMS

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CMS Identity Management System Announcement

  • CMS will soon transition from EIDM to a more streamlined system for creating

identity management accounts and requesting access to the Quality Payment Program website.

  • The new identity management system will be accessible via the Quality Payment

Program Sign In page.

  • CMS has been working with the clinician community to test the new identity

management system prior to going live to ensure that system changes will be beneficial for end users.

  • Anyone with an EIDM account will be automatically transitioned to the new identity

management system.

  • Additional information regarding this transition will be released shortly.
  • Click “Subscribe to Updates” at the bottom of the Quality Payment Program website to

receive important program information.

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EIDM Reminders

  • In order to submit data via the CMS Web Interface, you need:
  • An active EIDM account, and
  • The Web Interface Submitter role for your organization (MIPS group or Shared Savings

Program/Next Generation ACO).

  • Before you can request the Web Interface Submitter role, there must be a user in

your organization with:

  • An approved Security Official role (MIPS Groups), or
  • An approved ACO Security Official role (Shared Savings Program/Next Generation

ACOs).

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EIDM Reminders

  • These roles (Web Interface Submitter, Security Official, ACO Security Official) are

requested through the ‘Physician Quality and Value Programs’ application accessible via the Sign In link on the Quality Payment Program website.

  • The first Security Official or ACO Security Official will need to create the organization

(MIPS group or ACO) as part of their role request.

  • Once the Security Official or ACO Security Official role has been approved, other

users can request the Web Interface Submitter role for that organization.

  • To avoid delays in accessing the system, make sure your EIDM account is active

(change password at least every 60 days).

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EIDM User Guides

  • EIDM user guides provide step-by-step instructions with screenshots for requesting

an EIDM Account and a role to access the ‘Physician Quality and Value Programs’ application in the CMS Enterprise Portal.

  • MIPS Groups
  • 2018 Enterprise Identity Data Management (EIDM) User Guide is available on the Quality

Payment Program Resource Library.

  • Shared Savings Program ACOs
  • 2018 Enterprise Identity Data Management (EIDM) ACO User Guide is available on the

Quality Payment Program Resource Library.

  • Next Generation ACO Model ACOs
  • Reference the following documents on the NGACO Connect Library, available at

https://app.innovation.cms.gov/NGACOConnect, for additional guidance:

  • “2018 NGACO EIDM Webinar 10.17.2018” document
  • “EIDM Account and Role Setup Webinar Recording 10-17-2018”

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Help with EIDM

Quality Payment Program

Monday through Friday 8:00 AM – 8:00pm (ET) E-mail: qpp@cms.hhs.gov Phone: 866-288-8292 TTY: 877-715-6222

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ACCESSING CMS WEB INTERFACE

Presenter: Ozlem Tasel, CMS Contractor

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Logging In

Step 1: Sign In to Quality Payment Program

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Logging In

Step 2: Enter Your Credentials

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Logging In

Step 3: Enter Your Verification Code

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface

Step 4: Click on the Eligibility Link on Left Navigation Menu

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface for ACOs

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Accessing the CMS Web Interface for ACOs

Step 5: Select Performance Year, APM Entities Tab and Click Start Reporting

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface for ACOs

Step 6: ACOs Enter the CMS Web Interface

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface for Groups

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Accessing the CMS Web Interface for Groups

Step 5: Select Performance Year, Practices Tab and Click Report As A Group

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface for Groups

Step 6: Click Start Reporting

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface for Groups

Step 7: Click Go To CMS Web Interface

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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Accessing the CMS Web Interface for Groups

Step 8: Groups Enter the CMS Web Interface

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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ASSIGNMENT & SAMPLING

Presenter: Sarah Grallert, CMS Contractor

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Assignment and Sampling Overview

  • The CMS Web Interface allows MIPS groups and ACOs to report data on a pre-

determined population of patients

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Beneficiaries are assigned to the organization. Assigned beneficiaries are assessed for their quality reporting eligibility, including measure- specific denominator eligibility. Eligible beneficiaries are sampled into applicable measures and loaded into the CMS Web Interface for quality reporting.

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Assignment: Overview

  • Assignment is the process of determining which beneficiaries are attributed to an
  • rganization, and is based on a predetermined algorithm.
  • A beneficiary assigned to an organization in one reporting year may or may not be

assigned to that same organization in the following reporting years.

  • For CMS Web Interface purposes, CMS uses:
  • Shared Savings Program assigned beneficiaries from the 3rd quarter assignment file;
  • Next Generation ACO aligned beneficiaries, updated for exclusions as of the 3rd quarter;

and

  • MIPS groups assigned beneficiaries as of October 26, 2018.

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Assignment Methodologies

  • MIPS groups reporting via the CMS Web Interface:
  • See the 2018 CMS Web Interface & CAHPS for MIPS Survey Assignment Methodology

document available on the Resources Library page of the Quality Payment Program website at https://qpp.cms.gov/.

  • Next Generation Model ACOs:
  • Next Generation Alignment Methodology
  • Shared Savings Program ACOs:
  • 2018 Shared Savings Program Assignment Specifications

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CMS Web Interface Sampling Overview

  • Assigned beneficiaries may be sampled into one or more CMS Web Interface

measures, using a three step sampling process:

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Step 1: Determine if assigned beneficiaries are eligible for quality reporting. Step 2: Determine if beneficiaries eligible for quality reporting are denominator eligible. Step 3: Select a sample of denominator eligible beneficiaries for each measure.

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CMS Web Interface Sampling: Selecting the Sample

  • Each measure and composite measure will have its own beneficiary sample. In
  • ther words, each organization will have 13 samples of 616 beneficiaries, and one

sample of 750 beneficiaries (for the statin therapy measure).

  • The beneficiary’s place in the sample (e.g., 1, 2, 3, etc.) is referred to as the

beneficiary’s rank.

  • Each organization is required to confirm and complete data entry on 248

consecutive beneficiaries for each measure.

  • For more information, please see the 2018 CMS Web Interface Sampling

Methodology document available on the Resources Library page of the Quality Payment Program website at https://qpp.cms.gov/.

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EXCEL BENEFICIARY SAMPLE DOWNLOAD & UPLOAD

Presenter: Ozlem Tasel, CMS Contractor

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CMS Web Interface Excel Download

Step 1: Click Report Data

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CMS Web Interface Excel Download

Step 2: Click Download

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Download

Step 3: Select Beneficiary Sample With Data

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Download

Step 4: Click Download

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Data Update

Step 5: Populate your Spreadsheet with Data

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Upload

Step 6: Drag and Drop or Browse to Upload your Excel Beneficiary File

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Upload

Step 7: Click Upload to Confirm

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Upload

Step 8: View Upload Progress in Lower Left Corner

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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CMS Web Interface Excel Upload

Step 9: Verify Data Upload

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Note: The screenshots provided in this presentation are from a test environment and may not display exactly what you will see on your screen at the time of submission.

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MEASURES OVERVIEW

Presenter: Angela Stevenson, CMS Contractor

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2018 CMS Web Interface Measure Resources

  • The 2018 CMS Web Interface Measures and Supporting Documents are available on

the Quality Payment Program Resource Library.

  • 2018 CMS Web Interface Measures List – Includes CMS Web Interface measure number,

measure title, alternative measures numbers for other programs, and the measure

  • wner.
  • Narrative Measure Specifications and Performance Calculation Flows – Includes

identification of measure, NQF number (if applicable), Description, Improvement Notation, Initial Patient Population, Denominator, Denominator Exceptions and Exclusions, Numerator, Numerator Exclusions, Definitions, Guidance, Rationale, Clinical Recommendation Statements, Measure Flows with Sample Calculations for Performance Rates and Downloadable Resource Mapping Tables.

  • Web Interface Coding Documents – An Excel workbook that lists codes related to the

Denominator (including exception, exclusion, and exclusion drug codes if applicable), Encounter, and Numerator (including exclusion drug codes if applicable).

  • Release Notes – Includes list of changes to existing measures made since the release of

the 2017 CMS Web Interface Narrative Measure Specifications.

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2018 CMS Web Interface Measures – No Change from 2017

  • CARE-1: Medication Reconciliation Post-Discharge
  • DM-2: Composite (All or Nothing Scoring): Diabetes: Hemoglobin A1c (HbA1c) Poor Control

(>9%)

  • DM-7: Composite (All or Nothing Scoring): Diabetes: Eye Exam
  • HTN-2: Controlling High Blood Pressure
  • IVD-2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
  • MH-1: Depression Remission at Twelve Months
  • PREV-5: Breast Cancer Screening
  • PREV-6: Colorectal Cancer Screening
  • PREV-7: Preventive Care and Screening: Influenza Immunization
  • PREV-8: Pneumonia Vaccination Status for Older Adults
  • PREV-12: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • PREV-13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

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CMS Web Interface Measures – Changed in 2018

  • CARE-2: Falls: Screening for Future Fall
  • PREV-9: Preventive Care and Screening: Body Mass Index (BMI) Screening and

Follow-Up Plan

  • PREV-10: Preventive Care and Screening: Tobacco Use: Screening and Cessation

Intervention

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Updates to 2018 CARE-2

  • CARE-2: Falls: Screening for Future Fall
  • Removed the medical reason denominator exception for patients who are non-

ambulatory and added it as a denominator exclusion.

  • Denominator Exclusions: Patients who were assessed to be non-ambulatory during

the measurement period.

  • Denominator Guidance: Denominator Exclusion, count as non-ambulatory
  • nly if non-ambulatory at the most recent encounter during the

measurement period.

  • Denominator Exceptions: None

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Updates to 2018 PREV-9

  • PREV-9: Preventive Care and Screening: Body Mass Index (BMI) Screening and

Follow-Up Plan

  • Changed the lookback period for a BMI (or BMI with follow-up plan when the BMI is

abnormal) from 6 months to 12 months from the most recent visit in the measurement period.

  • Measure Description: Percentage of patients aged 18 years and older with a BMI

documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

  • Numerator: Patients with a documented BMI during the encounter or during the

previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

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Updates to 2018 PREV-10

  • PREV-10 Preventive Care and Screening: Tobacco Use: Screening and Cessation

Intervention

  • Three measure rates are now required to be reported for the measure.
  • Measure Description: Percentage of patients aged 18 years and older who were

screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.

  • Percentage of patients aged 18 years and older who were screened for

tobacco use one or more times within 24 months

  • Percentage of patients aged 18 years and older who were screened for

tobacco use and identified as a tobacco user who received tobacco cessation intervention*

  • Percentage of patients aged 18 years and older who were screened for

tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

* Measure rate used for performance calculation. Other rates reported are informational.

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Updates to 2018 PREV-10

  • Denominator:
  • Population 1: Equals Initial Population
  • Population 2: Equals Initial Population who were screened for tobacco use and

identified as a tobacco user

  • Population 3: Equals Initial Population
  • Denominator Exceptions:
  • Population 1: Documentation of medical reason(s) for not screening for tobacco

use (e.g., limited life expectancy, other medical reason)

  • Population 2: Documentation of medical reason(s) for not providing tobacco

cessation intervention (e.g., limited life expectancy, other medical reason)

  • Population 3: Documentation of medical reason(s) for not screening for tobacco

use OR for not providing tobacco cessation intervention for patients identified as tobacco users (e.g., limited life expectancy, other medical reason)

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Updates to 2018 CMS Web Interface Measures

  • Numerator:
  • Population 1: Patients who were screened for tobacco use at least once within 24

months.

  • Population 2: Patients who received tobacco cessation intervention.
  • Population 3: Patients who were screened for tobacco use at least once within 24

months AND who received tobacco cessation intervention if identified as a tobacco user.

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RESOURCES & WHERE TO GO FOR HELP

Presenter: Kayte Moore, CMS Contractor

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Resources

  • Quality Payment Program Help and Support
  • Website: https://qpp.cms.gov/about/help-and-support
  • Videos, webinars, online courses, learning network, in-person assistance, APM learning

systems, developer tools

  • 2018 Quality Payment Program Resource Library
  • Website: https://qpp.cms.gov/about/resource-library
  • 2018 MIPS Quality Performance Category
  • 2018 CMS Web Interface Measures and Supporting Documents
  • 2018 CMS Web Interface Sampling Methodology
  • 2018 CMS Web Interface Support Webinars
  • 2018 CMS Web Interface & CAHPS for MIPS Survey Assignment Methodology
  • 2018 CMS Web Interface Fact Sheet

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Resources

  • Shared Savings Program ACO:
  • Website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/sharedsavingsprogram/index.html

  • Quality Measures, Reporting and Performance Standards:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/sharedsavingsprogram/Quality-Measures-Standards.html

  • ACO Portal: https://portal.cms.gov/
  • 2018 Quality Measurement and Reporting Guides folder (in the Resources section)
  • Weekly ACO Spotlight Newsletter
  • Next Generation ACO Model:
  • Website: https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/
  • Connect Site: https://app.innovation.cms.gov/NGACOConnect/
  • Weekly Newsletter

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Get Help from CMS

  • Quality Payment Program
  • E-mail: QPP@cms.hhs.gov
  • Phone: 1-866-288-8292 (TTY 1-877-715-6222)
  • Medicare Shared Savings Program ACO
  • E-mail: sharedsavingsprogram@cms.hhs.gov
  • Next Generation ACO
  • E-mail: NextGenerationACOModel@cms.hhs.gov

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Q&A Session

  • To ask a question, please dial:

1-866-452-7887

  • Press *1 to be added to the question queue.
  • You may also submit questions via the chat box.
  • Speakers will answer as many questions as time

allows.

  • Ask most important questions first.

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