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Q.  Are Medicare ACOs subject to the 70% of patients from all payers rule for quality measure reporting?

A.  Our understanding is yes as it is discussed in the Federal Register and has been part of MIPS for several years.  


Q.  The 70% of patients from all payers seems overwhelming to our team.  How do we approach this task?

A.  We suggest you start with confirming your feeds for Medicare patients for which you have patient rosters and claims data.  Next, if you have your commercial rosters and claims data in our system, then it will be easy to identify patients with an encounter.  If you do not have commercial rosters and claims data in our system, we suggest using the QRDA III file that should be easily extracted from your EHR.  Keep in mind many patients will not qualify the measure due to age or diagnosis requirements. 

Q. How do we select the patients to meet the 70% of all patients from all payers requirement?

A.  Claims data will identify if a patient has had a qualifying encounter with a provider in your network.  70% of patients that had a qualifying encounter must be reported, if they meet the requirements of the measure such as age and diagnosis.

Q.  If a patient is not seen during the year, are they included in the 70%?

A.  No, as the patient did not have a qualifying encounter with a provider in your network.


Q. When does our organization need to make a decision about choosing QPP APP APM Entity or CMS Web Interface for 2021?

A. Health Endeavors will be requesting clients make a final decision on August 31, 2021.  


Q.  Is 2021 the final year for CMS Web Interface reporting using the random sample?

A.  Yes.


Q.  What are the available data imports to answer measures for QPP APP APM Entity - Medicare ACO

A.  QRDA III at end of year (October 5 and January 5 for final reporting).  85% of EHRs have a QRDA III extract function.  QRDA IIIs will also pull all patients, therefore meeting the 70% of patients from all payers requirement.  For year-round gap analysis and performance scoring we will use QRDA I, CMS Approved Claims; e.g. CPT II codes (see Measure Overview Document) and SMART on FHIR.  Manual key is also available but manual processes need to come to an end due to the increased volume of patients. 

Q.  What are pros and cons of CMS Web Interface vs. QPP APP APM Entity?

A.  QPP APP APM Entity is only 3 measures proactively reported.  This is significantly less than the 10 required for the CMS Web Interface.   In addition, the allowed data sources are more flexible under QPP APP APM Entity reporting.  

Q.  We are a hospital and think we should remove our independents in 2022

A.  We think this is a mistake as your organization has spent significant time and resources aligning independent clinics to your ACO. Now is your time to shine to assist them in achieving the highest possible score for MIPS upwards adjustments. 

Q.  Is it easier to leave the ACO and just do MIPS?

A.  No, as the requirements for ACOs are the MIPS requirements.

Q.  What is SMART on FHIR

A.  SMART on FHIR provides a platform to pull quality measure responses directly from the EHR into the Health Endeavors' central qualified registry repository 

Q.  What are the measures and allowed data imports for CMS Web Interface and QPP APP APM Entity?

A.  Click the link to Measure Overview Document

Q.  How is QPP APP APM Entity scored?  

A.  As it is 6 total measures (3 CQM and 3 Claims) then each measure is weighted 1/6.  Click the link to Measure Overview Document

Q.  What supporting documentation will be required for patients selected in the audit?

A.  The clinic will complete an attestation form and use submit a request to remit to us.  The attestation is a confirmation by the clinic that the patients selected in the audit have their measures documented in the EHR. 

Q.  Can you add other quality measures to track in the QPP APM Entity method?

A.  At this time the final QPP APM Entity specifications have not been released by CMS.  As soon as they are released, we will update this question.

Q.  In a multi specialty practice, would a Dermatologist be required to collect and report BP? Do you have a document listing the appropriate Category II codes? 

A.  Yes, if in the ACO and treated the patient it would be a qualifying encounter.  Either the dermatologist or the primary care physician in-network would need to report the BP.  The CPT II codes are in the Measure Overview Document.

Q.  What is a dCQM?

A.  A digital clinical quality measure extracted using FHIR.

Q.  If a patient has a qualifying encounter (for example an Annual Wellness Visit (G0438) for the Controlling Blood Pressure measure) from an ACO provider that is billed to a non-ACO TIN, would that qualify a patient for an inclusion into the measure denominator for the ACO reporting? OR, does the AWV need to be billed to an ACO TIN in order for the patient to be included in the ACO denominator?

A. The patient would be included in the measure denominator based only on qualified encounters billed to ACO participant TINs. So if a patient does not have a qualifying encounter within the ACO, they would not be included for that measure. ACOs are encouraged to collaborate inside and outside the ACO to obtain data to document quality actions for numerator performance. But a patient's inclusion in the eligible population for a quality measure would be determined by the visits billed within the ACO.

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