Easy may not be one of the first words that come to mind when you think of MIPS. However, attainable should become a word that you associate with submitting your data to attest for MIPS. Let’s look at how, where, when and what to report.

The deadline for data submission is March 31 at 8 PM EST. You do not want to wait however in case you find you have something missing. Start gathering all of your documentation right away then submit as soon as possible.

Registries have deadlines that are earlier in March so if you will be using a registry check with them as soon as possible.

There are multiple ways to submit your data. If you are part of an Alternative Payment Model there will be specific instructions through that entity. You will want to work with the support provided through the them.

If you are part of a group of more than 25 clinicians there is the option to report via the Centers for Medicaid and Medicare (CMS) Web Interface. On this website CMS will present you with some chosen patients and you enter information about Quality Measures you performed for those patients.

If you have a 2015 Certified Electronic Health Record (CEHRT) you can submit your data through the Quality Payment Program (QPP) website. That can be found at qpp.cms.gov. If you will be using the QPP website you will first go there to register for a HARP. The first individual to register will be a Security Official. You will need your Tax ID Number, PTAN, and all relevant NPIs. Once this is set up you will log in and see the below. Click on Eligibility & Reporting and you are ready.

Another option for reporting if you have a certified EHR is a direct attestation. You may be able to directly connect to the Centers for Medicaid and Medicare (CMS) directly through an Application Programming Interface (API). You can think of this like an App on your phone. The data will flow directly to CMS.

If you do not have a certified EHR or no EHR you can report via a third party intermediary. This would be a Qualified Registry or a Qualified Clinical Data Registry. There are lists of these registries on the QPP website.
If you do not have a certified EHR you also have the option to report via Medicare claims. This involves entering codes on claims to signify Quality measures have been performed.

How and What
When reporting via the QPP website you can report for the three categories in which you will have data. For the Quality category you will run a MIPS report from your certified EHR. The report will then be exported from the EHR in the QRDA III format. This is a special file format CMS requires for the submission of Quality data on the QPP site.

The Promoting Interoperability category can be reported in one of two ways on the QPP site. You can also export a QRDA III file from your certified EHR and upload it or you can do a manual entry. For the manual entry you will be answering yes/no questions or entering numerators and denominators

Improvement Activities are a manual entry. It almost seems too easy. You will search for the Improvement Activity or Activities you will be attesting you performed. Once you find it simply check the completed box next to it. Voila! You’re done.

You can also report all three categories via a registry. The registry may pull the data from your system for you or some registries require you enter the data manually. CMS has information on registries, their costs and so on. Be sure to shop for the one that best suits your practice.

Finally Quality can be reported via Medicare Part B claims. First you will want to choose which measures you will be reporting. Once you have chosen measures go to the QPP site resource library and download the specification sheets for the measures here. The specifications tell you what patients fit the measure as well as what codes are to be added to your claims to communicate that the measure has been met.


Here are some tips to keep in mind.

  • Do not wait.
  • Keep documentation of measures, correspondence with your vendor(s), and a screenshot of your submission in a physical and a virtual folder.
  • If you qualify for exclusions in the Promoting Interoperability category be sure to claim it or you will not be scored.
  • If you were approved for a hardship exception for PI and you want to use it do not upload or enter data for this category. If you are using a registry or your EHR to report be sure to communicate with them you do not want data reported for PI. If data gets reported it nullifies the hardship exception.
  • Don’t hesitate to contact us with any questions. Let us do the research for you.

You now have a good overview of how, what, where, and when to report.

If you need help at all please contact us at techassist@qsource.org or 844-205-5540.