How do I report my 2017 MIPS data to CMS using the Practice Fusion QCDR?

Practice Fusion has been recognized by CMS as a MIPS Qualified Clinical Data Registry (QCDR) for the 2017 performance year, and this offers several quality reporting benefits to your practice. QCDR participants will be able to:

  • Streamline the data review and submission required for MIPS participation, regardless of the pace you have chosen (test, partial, or full year)
  • Save time by reporting data for all three performances categories of MIPS directly through your EHR
  • Earn bonus points for end-to-end electronic reporting in the Quality performance category

Who can participate in the Practice Fusion QCDR? All Practice Fusion EHR users who were eligible to participate in MIPS in 2017 can register and consent to MIPS data submission using the Practice Fusion QCDR. Check your MIPS participation status on the CMS Quality Payment Program website. All QCDR participants must complete the registration and consent workflow in their MIPS Dashboard in order to submit data to CMS, even if you submitted a registration form outside the EHR earlier this year or in 2017.

This article outlines the two parts of the MIPS data submission workflow:

  1. Register and consent to MIPS data submission using the Practice Fusion QCDR
  2. Review, verify and submit data to CMS 

Note: Completing registration and consent workflow will not result in MIPS data being automatically sent to CMS.

Before you get started

  • Make sure all relevant chart notes from 2017 have been signed by the MIPS eligible clinician.
  • Make sure that you have set up your MIPS Dashboard watch list to include the measures and activities you plan to submit to CMS. Measures and activities that are not included on your watch list will not be submitted to CMS when reporting via the Practice Fusion QCDR.
  • Make sure that you have requested and approved a Physician Quality and Value Programs EIDM Role in the CMS Enterprise Portal so that you can view your MIPS data submission after it is sent via the QCDR.
  • If you are the MIPS eligible clinician, you will need an “EIDM Role” of Individual Practitioner with an “EIDM Role Type” of Provider Approver
  • If you are viewing data on behalf of a MIPS eligible clinician, you will need an “EIDM Role” of Individual Practitioner Representative with an “EIDM Role Type” of PQRS Provider 
  • Follow the steps below in the CMS EIDM User Guide to assign the appropriate EIDM roles with CMS.
  • Go to the CMS Enterprise Portal home page: https://portal.cms.gov/ 
  • Upon initial login, the CMS Enterprise Portal My Portal page is displayed. Select Request/Add Apps link on the My Portal screen page to begin the process of requesting a new user role request access to CMS Systems/Applications
  • Select the ‘Physician Quality and Value Programs’ domain and select ‘Request Access.’
  • At the top of the next screen, the Physician Quality and Value Programs application will be auto-populated. Under ‘Select a Group’, select ‘“Provider Approver” then select “Individual Practitioner”
  • Select ‘Next’ to complete the ‘Identity Verification’ section. The Identity Verification process will only be completed the first time a user requests a role in the Physician Quality and Value Programs domain in EIDM. 
  • If you have never completed EIDM role selection in the CMS Enterprise Portal, you may need to complete additional identity verification steps which begin on page 22 of the CMS EIDM User Guide.

Part 1: Completing the Practice Fusion QCDR registration and consent workflow 1. From your MIPS Dashboard, open the Actions menu and select Set up QCDR reporting.

2. Review the registration and consent details, then click Begin reporting setup. This workflow includes the initial required steps for setting up your MIPS data that will be reported to CMS via the Practice Fusion QCDR, including:

  • Indicating your practice’s Patient-Centered Medical Home status.
  • Indicating whether you intend to report the Advancing Care Information (ACI) performance category.
  • Claiming ACI Base Measure exclusions, if eligible.
  • Attesting to required ACI Prevention of Information Blocking statements, if eligible.
  • Providing consent to allow Practice Fusion to submit data to CMS on your behalf via the Practice Fusion QCDR.

3. Enter and verify the required information, including your NPI number, the Tax ID Number (TIN) that you use to submit Medicare Part B claims, and your preferred email address for QCDR communications. If your NPI and TIN details are already entered in your user profile, those fields will autofill; the email address will default to your Practice Fusion login email but can be edited if necessary. Check the verification box, then click Continue.

4. In the next few screens you will need to confirm the required details listed below:

  • Your Patient-Centered Medical Home (PCMH) status: If you’re in a certified or recognized patient-centered medical home, comparable specialty practice, or an Advanced Payment Model designated as a Medical Home Model, you’ll automatically earn full credit for the Improvement Activities performance category.
  • Indicate intent to report Advancing Care Information in Practice Fusion: Confirm whether Practice Fusion should include the ACI performance category in your MIPS data generated for QCDR submission.
  • Claim ACI measure exclusions, if eligible: If you intend to report ACI information in Practice Fusion, indicate whether you are claiming an exclusion for the e-Prescribing measure and/or the Health Information Exchange measure.
  • Review and attest to the required ACI Information Blocking attestations: If you intend to report ACI information in Practice Fusion, MIPS eligible clinicians must attest to three statements about how they implement and use certified EHR technology (CEHRT). For more information about ACI Information Blocking attestations, click here.

5. After the details regarding data described above are completed, you will be asked to consent to have your MIPS data submitted to CMS via the Practice Fusion QCDR. Review and agree to the consent language, then click Finish setup.

6. Review your reporting setup summary to ensure it is complete.

  • To make changes to select items in the setup, click Edit next to the item you want to change to be taken directly to that step.
  • To restart your setup workflow, select Restart setup. If you choose to restart your setup, your previous selections will be cleared and you will be required to select each answer again.
  • If there are no changes needed, click Close.

Next Steps

  • All MIPS data must be reviewed and verified before it can be submitted to CMS via the Practice Fusion QCDR.

Part 2: Completing the MIPS review,verify and submit workflow 1. Re-review your MIPS Watch List on the MIPS Summary tab and confirm that all the measures and activities you would like to report are included there in each of the Performance Categories you wish to report. To ensure the appropriate data is included in the JSON file you will submit to CMS, you complete this first step prior to selecting Verify and report for MIPS performance (2017) in the Actions menu or clicking Review and verify now in the gray banner.

2. From your MIPS Dashboard, open the Actions menu and select Verify and report MIPS performance (2017) or click Review and verify now in the gray banner at the top of your MIPS Dashboard. This option will only be available once you have completed the QCDR register and consent workflow.

3. Next, you will need to verify the accuracy and completeness of the  data within each performance category you selected to report. Click Verify next to each category to review the data that will be submitted to CMS.

  • Advancing Care Information (ACI): Review the Numerator and Denominator columns for each applicable measure and review the Status column for YES/NO measures (e.g. Security Risk Analysis).
  • The two rows that have the measure names EHR Technology Use Acknowledgement and ONC Good Faith Acknowledgement are indications that you completed the required ACI Information Blocking Attestations included in the registration workflow.
  • If you have earned the ACI bonus for “Use of Certified EHR Technology to complete certain Improvement” you will see that at the bottom of the table in a category labeled Bonus

Once you have independently confirmed your ACI data is complete and accurate, check the Result Verification box and click Save.

  • Improvement Activities: Review the Status column for each improvement activity to verify that the activities being submitted have the expected status. Once you have determined that your Improvement Activity data is complete and accurate, check the Result Verification box and click Save.

  • Note: If you indicated that you are a certified or recognized patient-centered medical home (PCMH), the status shown will be as 'Completed'. If you indicated that you are not a PCMH, the status will be shown as 'Incomplete'. 

  

  • Quality: Review the Performance Met, Performance Not Met, Initial Patient Population (IPP), Exclusion, and Exception columns to verify that your selected eCQM data is complete and accurate.
  • Performance Met represents the Numerator value in the MIPS dashboard.
  • Performance Not Met is equal to: (IPP value minus Numerator value minus Exclusion value minus Exception value)
  • Initial Patient Population is not visible in Practice Fusion. It is sometimes equal to the Denominator, but not always.
  • Exclusion is visible in Practice Fusion if the eCQM has an eligible exclusion.
  • Exception is visible in Practice Fusion if the eCQM has an eligible exception.

Once verified, check the Result Verification box and click Save.

4. Once you have completed review of your data from each applicable performance category and verified it as accurate and complete, you can submit your data to CMS. To do this, click Send data to CMS to submit your data to CMS via the Practice Fusion QCDR. You will need to refresh the page after you submit to view your returned results.

  • If the submission was successful, your MIPS Final Score will appear in the Report for MIPS tab of your MIPS Dashboard. When reviewing your MIPS Final Score, keep in mind that there may potentially be special scenarios that impact whether your final score shown from the API is your true final score.

5. Confirming your MIPS Data Submission. Verify that CMS received your MIPS data submission by checking your final score directly from CMS. Please log into the Quality Payment Program web portal (www.qpp.cms.gov) using your EIDM account information.

  • Make sure that you have requested and approved a Physician Quality and Value Programs EIDM Role in the CMS Enterprise Portal so that you can view your MIPS data submission after it is sent via the QCDR.
  • If you are the MIPS eligible clinician, you will need an “EIDM Role” of Individual Practitioner with an “EIDM Role Type” of Provider Approver
  • If you are viewing data on behalf of a MIPS eligible clinician, you will need an “EIDM Role” of Individual Practitioner Representative with an “EIDM Role Type” of PQRS Provider
  • Follow the steps in the CMS EIDM User Guide to assign the appropriate EIDM roles with CMS.
  • You should log into the Quality Payment Program webportal using your EIDM information to confirm whether the data was submitted accurately, regardless of the results you see in your Practice Fusion MIPS Dashboard. 
  • When trying to view the ACI (or IA) category in the QPP Web Portal, click on the "Registry" tab at the top of the screen next to the tab for Attestation. Then, scroll down and the category score will be displayed in red/pink. The total MIPS Final Score is not viewable in the QPP web portal.
  • If the results in the QPP web portal are not as you expected, reach out to Practice Fusion customer service for help with troubleshooting your submission. 

Additional Information for MIPS Data Submission

  • Updating Data: If you need to make changes to any of the measures in your MIPS Watch List after you have clicked on the Report for MIPS tab the first time (or anytime after you begin verifying your submission data), you will need to re-generate a new JSON file with your updated data.

    • If you want to edit some of the information that you submitted in the registration workflow, open the Registration and Consent modal from the Actions menu and select “edit” next to the appropriate category.

    OR

  • To restart your QCDR registration/consent workflow completely, open the Registration and Consent modal from the Actions menu and select Restart setup. Once you complete the registration flow, you can immediately go to the Report for MIPS tab and complete the verify steps again before submitting your data to CMS.

       

Quality Payment Program

  1. 2018 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  2. What is the MIPS Dashboard watch list and how do I use it?
  3. How does the MIPS Dashboard work?
  4. 2018 ACI Transition Measure: Medication Reconciliation
  5. 2018 ACI Transition Measure: Electronic Prescribing (eRx)
  6. 2018 ACI Transition Measure: Secure Messaging
  7. 2018 ACI Transition Measure: Security Risk Analysis
  8. 2018 ACI Transition Measure: Health Information Exchange
  9. 2018 ACI Transition Measure: Immunization Registry Reporting
  10. 2018 ACI Transition Measure: Specialized Registry Reporting
  11. 2018 ACI Transition Measure: Syndromic Surveillance Reporting
  12. 2018 ACI Transitional Measure: View, Download, or Transmit (VDT)
  13. 2018 ACI Transition Measure: Provide Patient Access
  14. 2018 ACI Transition Measure: Patient-Specific Education
  15. 2017 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  16. How do I report my 2017 MIPS data to CMS using the Practice Fusion QCDR?
  17. What is the Advancing Care Information (ACI) Performance Category for MIPS and how is it scored?
  18. 2017 ACI Transition Measure: Security Risk Analysis
  19. 2017 ACI Transition Measure: Electronic Prescribing (eRx)
  20. 2017 ACI Transition Measure: Provide Patient Access
  21. 2017 ACI Transition Measure: Health Information Exchange
  22. 2017 ACI Transition Measure: View, Download, or Transmit (VDT)
  23. 2017 ACI Transition Measure: Patient-Specific Education
  24. 2017 ACI Transition Measure: Secure Messaging
  25. 2017 ACI Transition Measure: Medication Reconciliation
  26. 2017 ACI Transition Measure: Immunization Registry Reporting
  27. 2017 ACI Bonus Measure: Syndromic Surveillance Reporting
  28. 2017 ACI Bonus Measure: Specialized Registry Reporting
  29. What is the Improvement Activities Performance Category for MIPS?
  30. What are the Quality performance category reporting requirements for MIPS?
  31. What is the difference between the two Advancing Care Information measure sets available in 2017?
  32. Advanced APM: What is Comprehensive Primary Care Plus (CPC+)?
  33. Which Improvement Activities Qualify for the Advancing Care Information (ACI) Bonus Score in 2017?
  34. How is the MIPS Final Score Calculated?
  35. MIPS for Small, Rural and Underserved Practices
  36. How do I contact CMS about the Quality Payment Program?
  37. What is the Practice Fusion QCDR?
  38. How do I indicate interest in the Practice Fusion QCDR and get my MIPS estimated scores?
  39. Chronic Care Management FAQs
  40. How do I export a JSON file for 2017 MIPS reporting?

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