We are closely approaching the end of Year 1 of the Merit-based Incentive Payment System (MIPS) and to aim for a positive reimbursement come the 2019 payment year, an individual provider or a group of providers must report on Quality, Advancing Care Information, and Improvement Activities. For the Quality performance category, specifically, a provider or group is required to report at least 6 quality measures, including 1 outcome or high priority measure, for a minimum of 90 continuous days up to the full calendar year (January 1, 2017 – December 31, 2017).
If you are planning to report CMS147 Preventative Care and Screening Influenza Immunization as one of your MIPS quality measures for the 2017 performance period via the Electronic Health Record (EHR) submission method, we would like to share some items to consider.
- Many eCQMs available for 2017 MIPS were designed to be reported using a full calendar year. However, the MIPS transition year allows for reporting of these eCQMs for a minimum 90-day reporting period, also referred to as measurement period. While reporting on the full year may be more representative of the care provided by an individual MIPS eligible clinician or group and potentially yield a higher performance, these measures can still be reported for the minimum 90-days. In the case of CMS147, numerator compliance is achieved when an Influenza vaccine was administered or previous receipt of the vaccine was communicated by the patient <= 153 days before the start of the measurement period or <= 89 days after the start of the measurement period. While this measure was specified to capture the flu season, these parameters can be applied to whichever measurement period is selected for 2017 MIPS reporting, if less than a year. CMS advises data should only be collected for the flu season and a 90-day reporting period should not include any dates between April and September.
- When a patient declines the Influenza vaccine, the reason why must be documented as well as Nomenclature Mapped in the Query and/or Grouped Response Dictionaries. A simple “No” response does not indicate the patient refuses the vaccine—it just indicates they have not yet received it. Given that response, it is important to document – (1) Influenza vaccine administered during the encounter (numerator compliant); or (2) patient refuses the Influenza vaccine. If a refusal reason is documented, the patient will fall out of the denominator as a denominator exception.
- The vaccination “refusals” or “not indicated” are a two-step process:
- As stated above, it is necessary to document the reason why the vaccine is not administered – for either medical- or patient-related reasons.
- It is also necessary to perform Negation Mapping in the MIS Mapping dictionary when a patient does not get the vaccine for either medical or patient reasons. This step allows the OneView logic to associate the reason why the vaccine was not administered to the step in the logic that is expecting to see this activity. The “Contra or Negation” Query is mapped to the OID Value Set for the Immunization Procedure Performed or Immunization Administered.
By Theresa Jasset at 19 Dec 2017, 11:57 AM