By using this checklist you agree that Sevocity, Conceptual MindWorks, Inc and their affiliates are not responsible for the accuracy of this checklist and that you are solely responsible for ensuring that your practice and providers are in compliance with MIPS requirements.
Determine if your Provider(s) must participate in MIPS for the reporting year: https://qpp.cms.gov/participation-lookup Review MIPS Program and Requirements: https://qpp.cms.gov/mips/overview Determine if you will report as a group or individual: https://qpp.cms.gov/mips/individual-or-group-participation Ensure your EHR is 2015 Certified: https://chpl.healthit.gov/#/search Determine your reporting method for the year: EHR, QCDR, Qualified Registry, or CMS Web Interface (only groups of 25 or more providers). For more information see “How Should I Submit Data”: https://qpp.cms.gov/mips/reporting-options-overview Determine your goal – avoiding the penalty (minimum of 45 points), additional reimbursement/positive adjustment (minimum of 85 points) or somewhere in between. Note that the 2022 negative payment adjustment for the 2020 reporting period is 9%: https://www.aafp.org/practice-management/payment/medicare-payment/mips.html 15%: Cost Reports (https://qpp.cms.gov/mips/cost?py=2020) – Review your practice’s prior results and determine if there are any changes you can make to improve results. 45%: Quality Measure Reports – Select 6 Quality Measures to report (https://qpp.cms.gov/mips/quality-measures?py=2020) Make sure the measures you select are supported by the reporting method you have selected. Also make sure you know what you need to do and document to achieve your targeted results. Hint: To achieve the best results, make sure you understand how each measure works for your specialty and EHR. Specialty associations are great resources. target #s better than the Quality Benchmarks: https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 25%: Promoting Interoperability – https://qpp.cms.gov/mips/promoting-interoperability?py=2020) Review your EHR’s PI capabilities and reporting. Make sure you have requested/enabled all required functionality such as Patient Portal and DIRECT messaging and you know what you need to do and document to achieve your targeted results.
15%: Improvement Activities – Select Your Practice Improvement Activities (https://qpp.cms.gov/mips/improvement-activities?py=2020) . Make plans to implement required processes to achieve, measure and report your targeted results.
Perform or Review your annual HIPAA Security Risk Analysis 45%: Quality Measure Reports – Review results periodically and take corrective action 25%: Promoting Interoperability – Review results periodically and take corrective action 15%: Improvement Activities – Review results periodically and take corrective action
Estimate total points periodically: 45 or more points – avoid the penalty, 85 or more points – eligible for positive adjustment
Register for EIDM and/or Complete Annual EIDM Certification: https://portal.cms.gov/wps/portal/unauthportal/home/
Submit Quality Measures, Promoting Interoperability and Improvement Activity reporting using your selected method by the CMS deadline. Note that some reporting methods require prior registration.