2021 Targeted Review Deadline October 21
October 14, 2022

2021 Targeted Review Deadline October 21

MIPS ECs and groups may request that CMS review the calculation of their MIPS payment adjustment factor(s) through a process called targeted review. If an EC or group believes an error has been made in the calculation of their MIPS payment adjustment factor(s), they may request a targeted review until October 21, 2022. Some examples of previous targeted review circumstances include the following:

  • Data was submitted under the wrong Taxpayer Identification Number (TIN) or National Provider Identifier (NPI).
  • Eligibility and special status issues (e.g., the EC or group fell below the low-volume threshold and should not receive a payment adjustment).
  • Performance categories were not automatically reweighted even though the EC or group qualified for reweighting due to extreme and uncontrollable circumstances.

ECs and groups can request a targeted review by going to the Quality Payment Program website.

CMS requires documentation to support a targeted review request, which varies by circumstance. Once submitted, the EC or group will be contacted by a representative with information about any specific documentation required. If the targeted review request is approved and results in a scoring change, CMS will update your final score and/or associated payment adjustment (if applicable), as soon as technically feasible. Targeted review decisions are final and not eligible for further review.

For more information about how to request a targeted review, please refer to the 2021 Targeted Review User Guide (PDF). For more information on payment adjustments please refer to the 2023 MIPS Payment Year Payment Adjustment User Guide (PDF).

MIPS improvement activity (IA) component: final 90-day period started October 1

To earn points in the IA component an eligible clinician or group needs to perform or participate in any improvement activity for a minimum of ninety consecutive days. The final 90-day period started October 1 and ends December 31, 2022.

For groups to attest to an activity, at least 50% of the clinicians (under the Tax ID number [TIN]) must perform the same activity during any continuous 90-day period, or as specified in the activity description, within the same performance period.

As a reminder, practices should maintain documentation regarding the IA for 6 years. Documentation should include a list of the NPIs that participated in the activity as well as how the IA was completed.

NACOR practice audits to begin in November

To remain in good standing as a Qualified Registry and Qualified Clinical Data Registry, AQI and its registry, NACOR, is required to submit an annual data validation plan to the Centers for Medicare & Medicaid Services (CMS).

To help ensure continued compliance with CMS data validation standards, AQI will be auditing the Quality, Improvement Activity, and Promoting Interoperability components for randomly selected practices. Practices selected for audit will be notified via certified letter within the next 30 days with instructions on how to complete the audit.

For more information, email askaqi@asahq.org.

Review your NACOR dashboard

Practices that have recently uploaded new data files should 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 2022 MIPS Performance Period are:

  • Submit 12 months of data (January – December 2022).
  • 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 60 to 75 points for the 2022 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

October Office Hours

Office hours were cancelled for October. The next office hours will be scheduled once CMS has released the Physician Fee Schedule Final Rule for 2023.

If you have any suggestions for topics to be discussed during office hours email askaqi@asahq.org.

2022 Reporting Deadlines

NACOR Registration: October 3, 2022

January through November 2022 data submission: January 31, 2023

Individual Quality Reporting Consent Submission: January 31, 2023

Improvement Activity Attestation: January 31, 2023

CMS Opt-Out for Individual Reporting: January 31, 2023

TIN/NPI Reconciliation: January 31, 2023

All data submissions: February 15, 2023

Contact AQI

Register: qcdr@asahq.org

NACOR Dashboard support: NACORSupport@asahq.org

Ask AQI: AskAQI@asahq.org

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