How to bring it home at the end of the performance year!

We are coming into the home stretch of the MIPS performance period. Let’s talk about all of the things to button up for 2020 so you are ready for data submission first thing in January.

Let’s go through each category.


One of the most important drivers in improving your cost score is to be sure you have communicated to the Centers for Medicare and Medicaid Services (CMS) the true health status of your patients. CMS calculates your cost based on risk factors which include how ill they are. To do so you want to be sure you have submitted all pertinent diagnosis codes for your patients. This must be done each year. The best way to accomplish this is through the Annual Wellness Visit (AWV). You can focus on performing AWVs on any patients that have not yet had one.

Improvement Activities

You may already have accomplished what is needed for this category. If you have an EHR there is an Improvement Activity that involves expanded hours. This means you have access to their records and can assist them after hours. It also includes the same or next day appointments.

If you do not have an EHR there are several that you may have already done and some that are not difficult to meet. The important thing for this category is that you know which one you will be reporting and you gather the recommended documentation. You can find a data validation file here. Within that file it will show you the recommended documentation. You will want the documentation over a period of 90 days.


Quality data is reported for the entire year. If you have an EHR you will want to run your MIPS Quality reports for the year to review how you have been doing.

If you are reporting Quality via Medicare Part B a chart audit could be helpful. You can pull random charts and the corresponding chart to see if the measures were performed and the Quality Data Codes were sent as well.

After reviewing these a meeting with pertinent staff to address deficiencies will help everyone keep their eye on the ball for the remainder of the performance period.

Promoting Interoperability

This is another category with a 90 day performance period. You may want to run a PI report for a couple of 90 day periods that possibly have already passed. It’s possible your performance is already good. Of course, you do not necessarily want to rest on your laurels. You could review the most recent 90 days of PI for your practice and work to improve any measures that are not quite there.

Now let’s talk about each of the pieces of PI

e-Prescribing – in working with practices rarely is this an issue. If it is and you feel you are doing on the e-prescribing you can check with your vendor to be sure there isn’t an issue with how these are being entered or some issue with your EHR.

Health Information Exchange – there is an exception for this if you make less than 100 referrals. You may want to run a report for previous 90 day periods to see if you will be able to use this exception. If not be sure you have contacted practices with which you are familiar to get information on sending records to them via Direct email. You may need to work with their IT person to get this working. You will also want to concentrate on larger practices and hospital systems as they are more likely to have the technology in use.

Provider to Patient Exchange – if you are lacking in this category speak to staff to be sure they are promoting or even assisting patients with accessing the patient portal.

Public Health and Clinical Data Exchange – be sure to check with all of the societies in which clinicians in your practice are members to see if they have registries with which you can engage. If there is one but there is an expense you can go here to sign up for the free CDC Survey registry.

One last thing to keep in mind is as a small practice you can use the PI Hardship Exception. You will need to log in to the QPP site. Once you log in there is a link to Exceptions on the left. You will choose the PI Exception form and use Small Practice as the reason.

As always feel free to reach out to us if you need any help. You can call us at 844-205-5540 or email us at