Quality Performance Category Collection Types
The CMS Web Interface will sunset as a collection type and submission type for traditional MIPS, beginning with the 2023 performance period. The CMS Web Interface will remain an available collection type only for Medicare Shared Savings Program Accountable Reporting Organizations reporting via the APP in the 2023 and 2024 performance periods.
Improvement Activities Performance Category
The CMS is:
- Adding four new improvement activities;
- Adopt certified health information technology for security tags for electronic health record data;
- Create and implement a plan to improve care for lesbian, gay, bisexual, transgender, and queer patients;
- Create and implement a language access plan; and
- COVID-19 vaccine achievement for practice staff.
- Modifying five current improvement activities; and
- Removing six current improvement activities.
The six improvement activities that will be removed for the 2023 performance year are:
- IA_BE_7: Participation in a QCDR, that promotes use of patient engagement tools;
- IA_BE_8: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive;
- IA_PM_7: Use of QCDR for feedback reports that incorporate population health;
- IA_PSPA_6: Consultation of the Prescription Drug Monitoring Program;*
- IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes; and
- IA_PSPA_30: PCI Bleeding Campaign.
*Commonly reported by RISE registry users.
Promoting Interoperability (PI) Performance Category
Public Health and Clinical Data Exchange Objective
The CMS is modifying the options for active engagement for the Public Health and Clinical Data Exchange Objective measures.
Query of Prescription Drug Monitoring Program (PDMP) Measure
The CMS is making this a required measure beginning with the 2023 performance period.
Health Information Exchange (HIE) Objective
The CMS is keeping the two existing options for satisfying the HIE objective and adding a third option (Participation in the Trusted Exchange Framework and Common Agreement [TEFCA]) for the 2023 performance period.
PI Measure Points
The CMS adjusted the individual PI measures maximum points, beginning with the 2023 performance period.
PI Reweighting
The CMS is discontinuing automatic reweighting for the following clinician types, beginning with this 2023 performance period:
- Nurse practitioners;
- Physician assistants;
- Certified registered nurse anesthetists; and
- Clinical nurse specialists.
MIPS-eligible clinicians, groups and virtual groups with the following special statuses will continue to receive automatic reweighting:
- Ambulatory surgical center based
- Hospital based
- Non-patient facing
- Small practice
Cost Performance Category
The CMS is establishing a maximum cost improvement score of 1 percentage point out of 100 percentage points available for the cost performance category, starting with the 2022 performance period. It notes that all MIPS-eligible clinicians will receive a cost improvement score of zero percentage points for the 2022 performance period because cost measure scores were not calculated for the 2021 performance period. It is establishing this policy to adhere to the statutory requirement of accounting for improvement in the assessment of performance under the cost performance category.