2020 MIPS Final Score Update
August 20, 2021

2020 MIPS Final Score Update

On August 16, the Centers for Medicare & Medicare Services (CMS) sent the following message through their listserv:

The Centers for Medicare & Medicare Services (CMS) will be updating the Merit-based Incentive Payment System (MIPS) performance feedback and final scores for some clinicians for performance year 2020 and the associated MIPS payment adjustment information for payment year 2022.

We are committed to ensuring transparency in our program and alerting clinicians as soon as possible when issues are discovered. Our intention is to provide clinicians advanced notice that they may see some change to their current final scores and payment adjustment information. Additionally, because of these expected changes we will also be extending the targeted review period.

More details about what will change from the initial release, who is impacted and how this will affect MIPS payment adjustments, as well as the new targeted review period deadline are coming soon. We appreciate your patience as we work to confirm the information we’re providing you is accurate.

Questions should be directed to the Quality Payment Program Help Desk at 1 (866) 288-8292 or by e-mail at QPP@cms.hhs.gov. To receive assistance more quickly, please consider calling during non-peak hours—before 10 a.m. or after 2 p.m. ET.

Review your NACOR dashboard

Remember to review your 2021 quality reports in the NACOR dashboard. For practices that have uploaded a new data file, AQI encourages a member of your practice to review the NACOR dashboard as it allows you to monitor your providers' performance, as well as pinpoint any problems with the data and make necessary corrections prior to data submission deadlines.

Data completeness requirements for the 2021 MIPS Performance Period are:

  • Submit 12 months of data (January – December 2021).
  • Report a minimum of six measures with at least one outcome or high priority measure.
  • Measure must meet the 20-case minimum to be scored.
  • Reporting rate must be at least 70% of all eligible cases across all payers for each measure reported.

Note: The minimum point threshold to avoid a negative payment adjustment has increased from 45 to 60 points for the 2021 performance year. It is important to check the measure performance rates for your practice to make sure the measures reported will earn the maximum points allowed for the Quality Component.

As a reminder, section 8 of the Addendum for Quality Reporting to the NACOR Participation Agreement states that your practice "and each EC agree, and Participant shall require each EC, to review his/her measure results in AQI at least four times a year and provide timely feedback to AQI on the measures that will be reported on the EC's behalf."

If there are questions about the dashboard results, submit a ticket to nacorsupport@asahq.org.

Reporting AQI 70: Prevention of Arterial Line-Related Bloodstream Infections

This measure consists of two performance rates AQI70a: Brachial, Radial, Posterior Tibial, or Dorsalis Pedis Arterial Lines and AQI70b Femoral and Axillary Arterial Lines. In order to be scored on this measure, clinicians must have at least one case reported for both AQI70a and AQI70b.

The performance rates for part a and part b will be determined by the numerator code that is reported:

  • 70a: 11A74, 11A75, or 11A76
  • 70b: 11A77, 11A78, or 11A79

In the data file, the <QCDRMeasure> should be reported as:

  <!-- CORRECT REPORTING FOR MEASURE AQI70 (parts A and B) - Prevention of Arterial Line-Related Bloodstream Infections  -->
    <QCDRModifier xmlns:nil="true" />
    <QCDRModifier xmlns:nil="true" />
    <QCDRModifier xmlns:nil="true" />
    <QCDRModifier xmlns:nil="true" />

For questions, email askaqi@asahq.org.

2021 Reporting Deadlines

NACOR Registration: October 1, 2021

January through November 2021 data submission: January 31, 2022

Individual Quality Reporting Consent Submission: January 31, 2022

Improvement Activity Attestation: January 31, 2022

CMS Opt-Out for Individual Reporting: January 31, 2022

TIN/NPI Reconciliation: January 31, 2022

All data submissions: February 15, 2022

Contact AQI

Register: qcdr@asahq.org

NACOR Dashboard support: NACORSupport@asahq.org

Ask AQI: AskAQI@asahq.org

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