CMS MIPS Promoting Interoperability 6-Month Reporting Period
Keeping pace with regulatory requirements, like MIPS, can be a daunting task for physician practices. To help you save time this week we are unpacking the Promoting Interoperability (PI) measure, which mandates providers to demonstrate their commitment to EHR utilization to meet some key objectives and meet some non-EHR requirements. Let’s take a look at the PI basics for 2024…
Understanding Promoting Interoperability
The MIPS Promoting Interoperability measure, formerly known as the Meaningful Use program, focuses on promoting the seamless exchange of health information between providers and patients. It aims to enhance patient engagement, improve care coordination, and facilitate the exchange of health information securely.
What It Means for Providers
For healthcare providers participating in MIPS, meeting the Promoting Interoperability measure is essential for achieving a positive payment adjustment and avoiding penalties. The measure evaluates how well providers utilize certified electronic health record technology (CEHRT) to promote interoperability and improve patient outcomes.
The 180-Day Requirement
One specific aspect of the Promoting Interoperability measure that providers must now, in 2024, adhere to is the 180-day reporting requirement. This means that eligible clinicians must demonstrate the meaningful use of CEHRT for a continuous 180-day period during the MIPS performance year. This period can be any 180 consecutive days within the calendar year.
Who Has to Report
There's one clinician type and several special status designations that result in automatic reweighting. These clinicians, groups, virtual groups, and Alternative Payment Model (APM) Entities are exempt from reporting Promoting Interoperability data for the 2024 performance year:
Clinician type: Clinical Social Workers
Special status: Ambulatory surgical center (ASC)-based, hospital-based, non-patient facing, and small practice (Note: small practice is the only special status available to APM Entities.)
If you’re reporting as a group, virtual group, or APM Entity, all MIPS eligible clinicians in the group, virtual group, or APM Entity must qualify for reweighting for the group, virtual group, or APM Entity to be reweighted, unless the group or virtual group has a special status that qualifies them for automatic reweighting.
Beginning with the 2024 performance year, the following clinician types will no longer be automatically reweighted and are therefore required to report Promoting Interoperability data:
Physical therapists
Occupational therapists
Qualified speech-language pathologists
Qualified audiologists
Clinical psychologists
Registered dietitians or nutrition professionals
The PI Objectives
To meet the Promoting Interoperability measures fall under 4 main objectives during the 180-day requirement, providers must focus on several key areas:
Electronic Prescribing (e-prescribing) This objective includes 2 elements. The first is to fully utilize electronic prescribing for prescriptions overall. The second aspect requires physicians who are prescribing Schedule II, II, and IV drugs to query their Prescription Drug Monitoring System prior to ordering the scheduled medication.
Health Information Exchange This requirement can be met in one of three possible ways and requires a provider who sends out and/or receives patients from another setting of care to share that patient’s health information electronically. This can be done for each inbound or outbound referral through:
1. The EHR where the end user sends and/or receives that information within the integrated system.
2. Share health information for inbound and outbound referrals through a Health INformation Exchange (HIE) like your local, state, or commercially based systems.
3. The other option to earn credit for these measures is if your CEHRT vendor is connected to a TEFCA based exchange. This requires confirmation that your vendor is indeed connected to a TEFCA entity known as a QHIN.
Note, there are currently only 6 QHINs an EHR is or can be connected to to meet this measure in this manner.
Provider to Patient Exchange This objective includes one requirement to provide patients access to their information through the patient portal in a timely manner. While this has been a login standing objective it is critical to ensure that the portal is and remains enabled for new and existing patients to view, download, and transmit their information and that patient’s data is shared there consistently and within 4 business days of their respective visit.
Public Health and Clinical Data Exchange This objective is multi-objective and requires a MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries. Active engagement means that a MIPS eligible clinician is working towards, or is already, sending "production data" to a PHA or CDR. This engagement can be demonstrated in one of two ways.
The public health registries that are included within the first measure objective include: Immunization Registry and Electronic Case Reporting
The second measure under this objective includes: Public Health or Clinical Data Registry or Syndromic Surveillance Reporting
Non-EHR Promoting Interoperability Requirements
In addition to submitting measures, you must provide your EHR’s CMS identification code from the Certified Health IT Product List (CHPL) and submit a “yes” to:
The Actions to Limit or Restrict Compatibility or Interoperability of CEHRT (previously named the Prevention of Information Blocking) Attestation
The ONC Direct Review Attestation
The Safety Assurance Factors for EHR Resilience (SAFER) Guides Measure
The requirements for SRA and SAFER are your responsibility and happen OUTSIDE of the EHR, this is not something your vendor can do!
Bonus Points
You can earn 5 bonus points for submitting a "yes" response for one of the optional Public Health and Clinical Data Exchange measures (Public Health Registry Reporting, Clinical Data Registry Reporting, or Syndromic Surveillance Reporting).
How Are Measures Scored
For measures that require a numerator and denominator, we calculate the performance rate for each measure using the numerators and denominators you submitted, and then multiply the performance rate by the total points available for the measure or objective. For scored measures that require a "yes" or "no", we award full points for measures submitted with a "yes".
For the Public Health and Clinical Data Exchange objective, you’ll be awarded full points if a “yes” is submitted for the 2 required measures (Immunization Registry Reporting and Electronic Case Reporting) or one “yes” and one exclusion. You’re also required to submit your level of active engagement for these 2 measures.
You must report all required measures (submit a “yes”/report at least one patient in the numerator, as applicable, or claim an exclusion) or you’ll earn a zero for the Promoting Interoperability performance category. If exclusions are claimed, the points for those measures will be reallocated to other measures.
While participation in MIPS is mandatory for eligible clinicians, meeting specific measures within MIPS, such as Promoting Interoperability, can vary based on individual circumstances. However, failing to meet the requirements can result in financial penalties and a negative impact on reimbursement rates. The Promoting Interoperability category is not to be overlooked and the need to comply with a 180 day reporting period means getting started earlier is more important than ever.
If you need help to understand or meet any of the measures within the PI category call us for a FREE quote. We help clients use their existing tools and systems to meet PI objectives and provide expert guidance on Quality, Improvement Activities, and even Cost! We offer pay-as-you-go monthly support that aligns you with a dedicated resource to support your best MIPS score and reimbursement.
