It’s that time of year.  Kids are getting ready to go back to school, stores are eagerly promoting the upcoming holidays and medical practices are reviewing their Merit-based Incentive Payment System (MIPs) and/or Meaningful Use (MU) participation data.

Quick recap: The performance reporting period for MIPS 2021 is January 1, 2021 - December 31, 2021, with varying lengths of time data must be collected. Some MIPS categories require 12 months of data, while others require 90 days as follows: 

• Quality Measures: 12 months  
• Promoting Interoperability: 90 continuous days
• Improvement Activities: 90 continuous days  

Quality measures may be either electronic clinical quality measures (eCQM) submitted through Practice EHR and/or clinical quality measures (CQM) that will be submitted through an independent registry. The practice must identify six measures with one being outcome-based or identified as a high priority measure.  At least 70 percent of patient charts that qualify for each selected measure must meet the reporting requirements.  

 How to Start Reporting:    

1. Set up your HARP account  

• Instructions for creating a HARP profile and account can be found at: https://qpp.cms.gov/login?page=register   
  

2. Complete the Security Risk Assessment (SRA) 

• The primary purpose of the security risk analysis for MIPS/MU is to identify key technical vulnerabilities in the electronic Protected Health Information (ePHI) and EHR. Download the SRA tool at: https://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool 

• Access MIPS and MU reports from Home > Reports > Clinical to see if you meet the performance threshold for each of the selected quality measures. If the results are incomplete, or you need additional assistance, please don’t hesitate to reach out to the Practice Client Services team. 

• If you report CQMs, review the Quality – MIPS Report showing the performance rate for each measure ID.  
• If you report eCQMs, review the eCQM report checking for patients that are qualified or not. 

Performance thresholds for 2021: The performance threshold (60 points) is the number of points a clinician or group needs to avoid a penalty. The additional performance threshold (85 points) is the number of points needed to earn an additional bonus. Additional information can be found at https://qpp.cms.gov/  

MU: For state Medicaid programs that have not adopted MIPs requirements, please reach out to Practice EHR Client Services. Our team is happy to help with system configuration consistent with state reporting requirements.