Home Practice Resources Patient Safety and Quality of Care 2021 MIPS Toolkit

2021 Merit-based Incentive Payment System (MIPS) Toolkit

Background

The Medicare Access and CHIP Reauthorization Act of 2015— also known as MACRA—was signed into law on April 16, 2015. This law, which created the Quality Payment Program (QPP), changed the way physicians are paid for providing services under Medicare. It continued the move away from fee-for-service payment, and toward value-based payment approaches, which endeavor to pay clinicians based on the quality, value, and outcomes of the care they provide.

Clinicians can participate in the QPP via two separate tracks: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models. Under MIPS, clinicians earn payment adjustments (either bonuses or penalties) for Part B covered professional services based on four performance categories: quality, cost, improvement activities related to care processes and patient engagement, and use of certified electronic health record technology to support and promote the electronic exchange of health information (i.e., promoting interoperability). Next year, CMS plans to roll out MIPS Value Pathways (MVPs), a new reporting option for the QPP. For 2021, however, only the original framework for collecting and reporting data to MIPS (“traditional MIPS”) is available for participating clinicians. The 2021 MIPS performance year spans from January 1-December 31, and data collected for this timeframe must be reported by March 31, 2022. Payment adjustments based on 2021 data will be made in 2023.

This toolkit focuses on 2021 participation rules, performance categories, and scoring approaches for traditional MIPS reporting.

Participation in MIPS

CMS provides the QPP Lookup Tool to instantly allow providers to know if they are required to report.

A MIPS-eligible clinician is excluded from MIPS if he/she answers yes to any of the following:

  • Has enrolled as a Medicare provider after January 1, 2021
  • Is a Qualifying Alternative Payment Model (APM) Participant in an Advanced APM
  • Meets any of the following low-volume threshold criteria:
    • Sees 200 or fewer Medicare Part B patients
    • Performs fewer than 200 covered professional services to Part B patients
    • Has $90,000 or less in Medicare Part B covered professional services

If a MIPS-eligible clinician meets at least one of the above three low-volume threshold criteria, he/she can opt-in to MIPS reporting. To do so, clinicians must log onto the QPP portal and register to opt-in. Those selecting this option will then be subject to applicable payment adjustments (positive or negative).

If a MIPS-eligible clinician does not meet any of the three low-volume threshold criteria, he/she can still choose to report voluntarily to MIPS. These clinicians can gain reporting experience and receive performance feedback, as well as become eligible to have performance data published on Medicare’s Care Compare. However, they are not subject to payment adjustments, and their performance results will not be included in MIPS measure benchmark calculations.

Options for Participation

Providers may be eligible to report as an individual clinician, as part of a group, as part of a virtual group, or as an APM entity group. Those reporting as an individual are scored independently on the data they submit to CMS. Those reporting as a group submit data on measures and activities based on the aggregated performance of clinicians who are billing under a Taxpayer Identification Number (TIN). More specifically, CMS defines a group as a single TIN with 2 or more clinicians (as identified by their National Provider Identifier (NPI)), who have reassigned their Medicare billing rights to that TIN. At least one clinician within the group must be MIPS-eligible. The TIN’s payment adjustment will be based on the group’s final score from the MIPS performance categories. If someone wishes to submit data for both individual and group reporting, CMS will analyze both sets of data and use the option with the higher score.

Clinicians may also form virtual groups. These must be approved by CMS, and those interested in participating in MIPS via this option must register with CMS prior to the reporting year. More information on the virtual group option is provided on the CMS QPP website.

Beginning in 2021, CMS added the APM Entity group as a submitter type. The APM Entity group is composed of all eligible clinicians participating with an APM Entity at certain times during the year. CMS defines an APM Entity as one that participates in an Alternative Payment Model or other payer arrangement through a direct agreement with CMS or other payer, or through Federal or State law or regulation. Note that the performance categories are weighted differently for this option. Additional information is provided on the CMS QPP website.

Performance Category Weights, Scoring, and Payment Impact

For 2021, the weights of the quality and cost performance categories changed, compared to those used for 2020. The weight of the quality component decreased from 45 percent to 40 percent, while the weight of the cost component increased from 15 percent to 20 percent. The weights for the remaining components did not change. For 2021, the weights for the four performance categories are:

  • Quality: 40 percent
  • Cost: 20 percent
  • Promoting Interoperability (PI): 25 percent
  • Improvement Activites (IAs): 15 percent

Each category is scored separately, with the four component scores added together for a total score. Participants must achieve at least 60 points in order to avoid a negative payment adjustment (penalty). Those who do not participate will incur a 9 percent penalty on their 2023 Part B Medicare payments, and those falling between zero and <60 points will face a penalty to some degree. Those scoring more than 60 points will receive a positive payment adjustment (bonus) of some degree. MIPS is a budget neutral program, meaning the penalties must pay for the bonuses; thus, the amount of the bonuses will be determined once CMS determines the amount of funds available. Those scoring 85 or more points are deemed “exceptional performers” and will receive an additional bonus. The fund for exceptional performers was designated by Congress and is separate from the MIPS bonuses; however, like the regular bonuses, the size of the awards is determined by the number of people who qualify for them.

Performance Category: Quality

The Quality performance category focuses on measures that assess health care processes, outcomes, and patient experiences of care. For this performance category, participants must report data for at least 6 quality measures (one of which must be an outcome measure, or a high-priority measure in the absence of an applicable outcome measure). Participants can opt to report on more than six measures; in that case, CMS will use the 6 measures with the highest scores. In 2021, the weight for the Quality performance category is 40 percent (that is, this category accounts for 40% of the total MIPS score).

Data Collection Types

There are several different ways that measures can be collected and reported for MIPS. In 2021, participants may use a combination of any of these options to complete their MIPS reporting. The possible reporting options for each specific measure are listed in the measure specifications.

Medicare Part B Claims reporting (previously known as claims reporting) has traditionally been used by many urologists. However, this option may be used only by those who are members of a practice with 15 or fewer providers. This reporting option involves submitting extra CPT Category II codes (also known as Quality Data Codes or G codes) along with regular billing CPT codes and diagnosis codes on electronic or paper claims submitted to Medicare. Medicare then forwards these claims files to the processor.

MIPS Clinical Quality Measures (CQM) (formerly known as Qualified Registry) reporting may be used by both individuals and groups. It is accomplished by contracting with a CMS-approved data processing service that can compile patient claims data and generate reports on a provider’s or practice's behalf directly to the MIPS processor. Depending on the vendor, data can be transferred to the registry in a number of ways.

Electronic Clincal Quality Measures (eCQM) [formerly known as Electronic Health Record (EHR)] reporting involves either submitting one’s data directly to CMS or to a vendor who will then submit it to CMS on the provider or practice’s behalf. Check with your EHR vendor to find out what option(s) is available to you. Both individuals and groups may use EHR reporting, and this method may allow you to qualify for bonus points if all of your data is submitted via EHR.

A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity (such as a registry, certification board, specialty society, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. Individuals and groups may report via a QCDR. The AUA offers its own QCDR, the AQUA Registry. For more information, contact 855-898-AQUA (2782) or AQUA@AUAnet.org.

CMS Web Interface reporting is available to groups of 25 or more clinicians for quality reporting. Those wishing to use the Web Interface option must register with CMS before the deadline (usually in June). CMS plans to sunset this interface as a MIPS submission method as of 2022.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey. This is an optional measure for participating groups reporting through the MIPS program. The CAHPS for MIPS Survey measure is a patient experience measure; note that there are beneficiary sampling requirements for this measure.

Available Quality Measures

There are 209 individual measures (sometimes called “QPP measures” or “MIPS measures”) to consider for MIPS reporting in 2021, in addition to the 9 urology-specific measures that are available through AUA’s AQUA registry. Of these 218 measures, 53 are supported through the AQUA registry.

In order to help urologists identify relevant measures, CMS created a Urology Measures Set (note that the 9 AUA urology-specific measures are not included on this list, as they are reportable only through participation in the AQUA registry). If participants select 6 measures from this list, they do not need to report an outcome measure. However, they must select at least one high priority measure from the list.

Regardless of which measures are selected, a participant must report 70 percent of the applicable patients for any measure (with a minimum of 20 applicable patients). If this reporting threshold is not met, participants will receive a score of 0 for the measure (unless the participant belongs to a practice with 15 or fewer providers; if so the participant will receive 3 points for the measure).

The AUA recommends that participants consider the clinical conditions they treat, any practice improvement goals, work currently being done in the practice, and quality information that may already be reported to other payers or entities when selecting measures for MIPS reporting. In addition, participants should also consider possible scoring. CMS gauges how well participants score on a measure and assigns the participant a point total. The points for the six highest-scoring measures are added when tallying one’s score for the Quality category. Some measures only allow limited scoring (see the section on benchmarking, below, for more details). Therefore, participants should assess how well they can score on the measures they select to report to CMS.

Quality Measures Supported Through the AQUA Registry

The 53 measures available through the AQUA registry are listed below (click on the links for the measure specifications).

AQUA Urology Specific Measures (Non-QPP Measures)

  • AQUA8 -Hospital admissions/complications within 30 days of TRUS Biopsy [QCDR]
  • AQUA14 - Stones: Inappropriate Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment [QCDR]
  • AQUA15 - Stones: Urinalysis Performed Before Surgical Stone Procedures [QCDR]
  • AQUA16 - Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease [QCDR]
  • AQUA18 - Non-Muscle Invasive Bladder Cancer: Early Surveillance Cystoscopy for Non-Muscle Invasive Bladder Cancer [QCDR]
  • AQUA26 - Benign Prostate Hyperplasia (BPH): Inappropriate Lab & Imaging Services for Patients with BPH [QCDR]
  • MUSIC4-Prostate Cancer: Active surveillance/watchful waiting for low-risk prostate cancer [QCDR]
  • MUSIC10-Prostate Cancer: Confirmation Testing in low risk AS eligible patients [QCDR]
  • MUSIC11-Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months [QCDR]

QPP Measures

  • Measure #1 – Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #23 – Perioperative Care, Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) [MIPS CQM, Claims]
  • Measure #47 – Advance Care Plan [ MIPS CQM, Claims]
  • Measure #48 – Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM]
  • Measure #50 – Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM, Claims]
  • Measure #102 – Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients [MIPS CQM, eCQM]
  • Measure #104 – Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer [MIPS CQM]
  • Measure #110 – Preventive Care and Screening: Influenza Immunization [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #111 – Pneumococcal Vaccination Status for Older Adults [MIPS CQM, Claims, eCQM]
  • Measure #112 – Breast Cancer Screening [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #113 – Colorectal Cancer Screening [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #117 – Diabetes: Eye Exam [MIPS CQM, Claims, eCQM]
  • Measure #119 – Diabetes: Medical Attention for Nephropathy [MIPS CQM, eCQM]
  • Measure #128 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan [MIPS CQM, Claims, eCQM]
  • Measure #130 – Documentation of Current Medications in the Medical Record [MIPS CQM, Claims, eCQM]
  • Measure #134 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #236 – Controlling High Blood Pressure [MIPS CQM, Claims, eCQM, CMS Web Interface]
  • Measure #265 – Biopsy Follow-Up [MIPS CQM]
  • Measure #317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented [MIPS CQM, Claims, eCQM]
  • Measure #318 – Falls: Screening for Future Fall Risk [eCQM, CMS Web Interface]
  • Measure #357 – Surgical Site Infection (SSI) [MIPS CQM]
  • Measure #358 – Patient-Centered Surgical Risk Assessment and Communication [MIPS CQM]
  • Measure #370 – Depression Remission at Twelve Months [MIPS CQM, eCQM, CMS Web Interface]
  • Measure #431 – Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling [MIPS CQM]
  • Measure #438 – Statin Therapy for the Prevention and Treatment of Cardiovascular Disease [MIPS CQM, eCQM, CMS Web Interface]
  • Measure #462 – Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy [eCQM]
  • Measure #476 - Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia [eCQM]

Specifications for MIPS measures not supported through the AQUA registry are available on the CMS QPP website.

Scoring the Quality Category

MIPS participants earn points for the Quality category based on how their results compare to that of other participants. As detailed below, measure results are compared to benchmarks based on historical data to determine the number of achievable points for submitted measures. Next, bonus points are awarded as applicable, and a percentage score is computed. Then, the final score for the Quality performance category is calculated by weighting the Quality percentage score by the Quality weight (for 2021, this is 40 percent).

Quality Benchmarks

For each measure, for each reporting mechanism, a series of historical benchmarks has been established. CMS created a matrix where each measure has been divided into deciles, ranging from 3 to 10. Participants can use this matrix to determine into which decile his/her performance falls, then use this information to determine the score for that particular measure. For example, if a urologist reports Measure #130 Documentation of Current Medications in the Medical Record using Medicare Part B claims reporting, the range for this measure is:

Measure #130 Documentation of Current Medications in the Medical Record, Medicare Part B Claims Reporting

Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Deicle 10
0.07-99.66% 99.67-99.93% 99.94-99.99% 100%

Typically, to achieve 10 points for this measure, a participant’s results would have to reach 100 percent, meaning he/she correctly documented current medications for all the patients to which this measure was applicable. If a couple of patients were missed, the results for the measure would be less than 100 percent. In such a case, for this particular measure, the participant’s score would drop down to a maximum of 5 points. In fact, the measure result would need to be very close to perfection in order to get more than 3 points.

However, the scoring on Measure #130 is challenging because it is considered a “topped out” measure by CMS. This means most participants score very well on it. CMS has begun phasing out many of the topped out measures, and is trying to discourage participants from using these measures by awarding lower point values. For some topped out measures, CMS does not award the full 10 points, even if the measure results are perfect. For 2021, for measure #130, the highest number of points that can be awarded is 7 (again, only for those participants with perfect measure results).

In contrast, Measure #236 Controlling High Blood Pressure is not topped out; therefore, the ranges are wider:

Measure #236 Controlling High Blood Pressure, Medicare Part B Claims Reporting

Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Deicle 10
20-29.99% 30-39.99% 40-49.99% 50-59.99% 60-69.99% 70-79.99% 80-89.99% >90%

Each measure, and its reporting mechanism, has its own unique benchmarks. Thus, participants will want to assess the potential benchmarks when they contemplate which measures to report. As shown in the following example, reporting a measure through Medicare Part B claims reporting will have a different benchmark than reporting it through CQM (registry) or eCQM (EHR) reporting.

Measure #111 Pneumococcal Vaccination Status for Older Adults

Collection Type Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Deicle 10
Medicare Part B Claims 0.21-68.67% 68.68-76.31% 76.32-82.46% 82.47-87.56% 87.57-93.08% 93.09-97.89% 97.9-99.99% 100%
eCQM 0.01-20.43% 20.44-33.71% 33.72-44.69% 44.7-54.85% 54.86-63.21% 63.22-71.09% 71.1-78.79% ≥78.8%
MIPS CQM 0.03-35.1% 35.11-51.28% 51.29-61.89% 61.9-69.15% 69.16-74.99% 75.0-79.89% 79.9-85.82% ≥85.83%

If a measure does not have a historical benchmark, CMS will attempt to calculate one using 2021 data. If no historical benchmark exists and one cannot be calculated using 2021 data, CMS will award 3 points for that measure, no matter how well the participant scores, as long as the data completeness and case minimum requirements have been met.

The benchmark values for MIPS and QCDR measures are available in a zipped folder located on the CMS QPP website.

Quality Bonus Points

In 2021, it is possible to earn bonus points for the Quality performance category. These can be earned in the following ways:

  • Submitting 2 or more outcome or high priority measures
    • NOTE: This does not apply to the first required outcome or high priority measure
    • The total measure bonus points for high priority measure cannot exceed 10 percent of the total achievable points
  • Using Certified Electronic Health Record Technology (CEHRT) to submit measures to a registry/QCDR or CMA (end-to-end electronic reporting).

For those in a practice with 15 or fewer clinicians who submit data for at least one quality measure, six bonus points will be awarded. In addition, participants may be able to earn as many as 10 additional points if their score for the Quality category improved compared to their score in the previous year. The bonus is awarded using the formula: 10 x (increase in achievement percent score from prior performance year / prior performance year achievement percent score).

Calculating the Final Score for the Quality Performance Category

To calculate a provider’s Quality category score, one must use the benchmark information for each measure to determine the number of achievable points for that measure. Those points are added together, along with any bonus points that have been earned. That total is divided by total number of achievable measure points (in most cases, this is 60 points). If an improvement percent score has been earned, it is then added to this value to determine the final score. The score is displayed as a percentage, but a maximum score cannot exceed 100 percent.

If a participant scores perfectly on all 6 measures and achieved 10 points for each, that participant would receive a Quality percentage score of 100 percent (60/60 * 100%). However, most participants will not have perfect scores on each submitted measure. For example, a participant may have the following scores for six measures: 3, 8, 7, 4, 5, and 9, for a total of 36 points), along with 8 bonus points (6 because the participant is a solo practitioner and 2 more points for an additional outcome measure). The total number of points would be 44, which is then then divided by 60, (this equals 73 percent). But this participant is also awarded an improvement percent score of 2 percent. Then, that participant’s percentage score for the Quality category is 75 percent. Finally, the formula for determining the total points for the Quality category is: (quality performance category percent score) x (quality category weight) x 100

Using the example above, the Quality performance category score would be: 75 percent x 40 percent x 100 =30 points.

Note that the Quality category weight might change for some participants. For example, if given an exception for the Promoting Interoperability performance category, the quality category weight becomes 65 percent (40 percent + 25 percent) in 2021. If an exception is given for the Improvement Activities performance category, the Quality category would be reweighted to 55 percent (40 percent + 15 percent).

If a practice has more than 15 eligible clinicians with at least 200 cases, CMS will calculate the 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups measure, based on claims the practice submitted for the year. Providers do not need to do any work for this calculation: it is all done by CMS. This measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN) and assesses each group’s readmission rate. This measure was excluded from scoring for 2020, but there is no guarantee it will be excluded for 2021.

Performance Category: Cost

The measures included in the Cost performance category assess the overall cost of care provided to Medicare patients, with a focus on the primary care they received; the cost of services provided to Medicare patients related to a hospital stay; and costs for items and services provided during specific episodes of care for Medicare patients. There are 20 cost measures available for 2021. In 2021, the weight for the Cost performance category increased to 20 percent (that is, this category accounts for 20% of the total MIPS score).

MIPS participants do not have submit performance data to CMS for the Cost category. Instead, CMS uses Part A and B Medicare claims data to calculate participants’ Cost category score.

The two population-based cost measures include:

  • Total Per Capita Cost (TPCC) – This measure assesses Medicare Part A and Part B costs during the year for attributed patients. Attribution of a given patient is based upon which clinician or group, respectively, bills allowed charges for primary care services delivered to that patient (determined by select E&M CPT/HCPCS codes). This measures is payment-standardized, risk-adjusted, and specialty-adjusted. There is a 20-case minimum for this measure. Urologists should not be attributed primary care patients; however, the AUA still recommends that providers review their annual reports to ensure that this has not happened.
  • Medicare Spending per Beneficiary (MSPB) Clinician - The MSPB Clinician measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (i.e., the period immediately before, during, and after a patient’s hospital stay). An MSPB episode includes most Medicare Part A and Part B claims during the episode, specifically claims with a start date between three days before a hospital admission (the “index admission” for the episode) through 30 days after hospital discharge. The measure excludes certain services that are unlikely to be influenced by the clinician’s care decisions. Inpatient medical episodes are attributed separately from inpatient surgical episodes. The case minimum for this measure is 35 episodes.

There are also 18 episode-based measures available for the cost performance category. These measures differ from the population-based cost measures in that they include only items and services that are related to the episode of care for a specific clinical condition or procedure, as opposed to all of the Medicare part A and B services over a specific timeframe. The length of the episode varies, depending on the measure. Three types of episode-based cost measures have been developed:

  • Procedural: These measures focus on procedures of a defined purpose or type. The case minimum for these measures is 10 episodes.
  • Acute inpatient medical condition: These measures represent treatment for a self-limited acute illness or treatment for a flare-up or exacerbation of a condition requiring a hospital stay. The case minimum for these measures is 20 episodes.
  • Chronic condition: These measures assess costs for ongoing management of a long-term health condition. NOTE, however, these measures are not available for the 2021 MIPS performance period.

The Renal or Ureteral Stone Surgical Treatment measure is a risk-adjusted, procedural cost measure applicable to many urologists. As a procedure measure, the case minimum is 10 episodes. The episode window for this measure spans from 90 days prior to the procedure to 30 days after.

Calculating the Final Score for the Cost Performance Category

For the Cost performance category, CMS will compare participants’ performance to that of other MIPS-eligible clinicians and groups during the performance period. More specifically, to calculate the score for each measure, CMS will determine the ratio of standardized observed episode costs to the expected costs and multiply that value by the average episode cost (benchmark).

For each scored measure, CMS will then assign 1-10 achievement points, based on the decile in which the score falls. The Cost performance category percent score is calculated as the total number of achievement points earned divided by the number of possible achievement points (i.e., the total number of scored measures times 10). Note that not all clinicians will quality for all cost measures, and some may not qualify for any.

As an example, if a participant is scored on two cost measures (7 points for one and 6 points for the other), the Cost performance category percent score would be ((7+6)/20)*100=65%.

The formula for determining the total points for the Cost category is: (cost performance category percent score) x (cost category weight) x 100.

Using the example above, the Cost score would be: 65 percent x 20 percent x 100 =13 points.

Performance Category: Improvement Activities

The Improvement Activities (IA) performance category measures participation in activities that improve clinical practice, care delivery, and outcomes. Participants can select from over 100 activities that pertain to patient engagement, care coordination, patient safety, and other relevant areas. In 2021, the weight for the IA performance category is 15 percent (that is, this category accounts for 15 percent of the total MIPS score).

IAs must be implemented for at least one continuous 90-day performance period (during 2021) unless otherwise stated in the activity description. They can be reported by individuals or through group reporting. If a practice is using group reporting, at least 50 percent of the members of the practice must implement the same IA in order to earn credit, although they do not have to implement it at the same time.

Each IA is given a medium weight (10 points) or a high weight (20 points). The maximum number of points available for this performance category is 40. Some groups (e.g., small practices, rural practices, those in health professional shortage areas, and non-patient facing practices) earn 20 points for medium-weighted activities and 40 points for high-weighted activities. Those working in a recognized or certified patient-centered medical home or comparable specialty practice can receive the full 40 points for this category. All IAs must begin no later than October 3, 2021 (in order to have a full 90-day performance window).

Participants will attest to their improvement activities (note that this can be done directly or through a third party, such as the AQUA registry). Documentation supporting improvement activities is not required at the time of attestation. However, documentation should be compiled, and would be required in the event of a CMS audit. Participants must keep this documentation for six years after attestation. CMS has published requirements for this documentation. The AUA recommends that participants document as much information as possible about the activities you complete. For example, if administering a patient satisfaction survey for 90 days, note in the patient charts who received one and when. Or, if attending an Institute for Healthcare Improvement event, save proof of registration and any materials (slides, handouts, etc.) that may have been distributed for the event.

Getting Started

AUA suggests that MIPS participants analyze their practice prior to selecting IAs. Ask:

  • What are areas that need improvement?
  • What changes would improve patient experience?
  • Are you currently doing improvement activities that would qualify for this program?

Then, brainstorm what you can do. Hopefully, if you do need to start new activities, or amend existing ones, you can implement something that will not require a significant outlay of time, staffing or other resources (assuming it would still positively impact patient care, experience, or outcomes). For example, programs may be offered through your local hospital system or through an insurance program that could satisfy an IA requirement.

Selecting IAs

There are more than 100 IAs available for reporting. They are organized into eight categories, as follows:

  • Achieving Health Equity (AHE)
  • Behavioral and Mental Health (BMH)
  • Beneficiary Engagement (BE)
  • Care Coordination (CC)
  • Emergency Response and Preparedness (ERP)
  • Expanded Practice Access (EPA)
  • Patient Safety and Practice Assessment (PSPA)
  • Population Management (PM)

The AUA has reviewed the complete list of Improvement Activities and has identified several that most urologists should be able to easily implement or adapt for their practices. These activities are highlighted in blue. However, you should review the entire list to see if there are other IAs that may be more applicable to your practice. Some practices may find that an option not recommended by the AUA would be a proper fit.

Additionally, several activities are highlighted in green; these can be completed through use of the AQUA Registry, the AUA’s Qualified Clinical Data Registry (QCDR). If you are not yet a member of the AQUA Registry and wish to consider this reporting option, contact AQUA@AUAnet.org or 855-898- AQUA (2782) for more information. If you choose to participate in MIPS via a QCDR, you must select and attest each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR. Note, too, that reporting for some quality measures also will fulfill IA reporting requirements.

Remember you must participate in whatever activities you choose for at least 90 consecutive days. Also note that sometimes the work you do will satisfy multiple IAs, so you should consider taking advantage of this overlap. Finally, note that due to the COVID-19 public health emergency, CMS has continued the COVID-19 clinical data reporting improvement activity.

Improvement Activity Resources

Several links and resources included in this Toolkit are available to provide more direction and guidance. It is important to note that each practice is unique, and in order to improve the care provided to patients, it is best to individualize what you will be doing as much as possible. The models and information here can serve as a basis for something that you will need to tweak slightly to make applicable to your practice.

While the AUA identified 37 activities (highlighted in blue and green) as achievable for urologists, some will be easier than others. See below for additional details and resources to help with some of these activities.

  • IA_EPA_3 – Collection and use of patient experience and satisfaction data on access – This activity focuses on collecting feedback from your patients and then using this information to implement change in your practice. Many organizations offer patient satisfaction surveys. Practices can also design their own surveys focusing on questions they find more useful. The American Academy of Family Physicians offers advice and resources about such surveys. CMS now requires some degree of patient stratification such as race/ethnicity, disability status (if available), sexual orientation (if available), sex, gender identity (if available), and geography. After accumulating data for 90 days, the next step is reviewing it and determining how to take advantage of the information gathered. If all of your surveys are noting the same thing, it is either something you are doing very well or something that should be changed. Look for small steps that can make a big difference but will not greatly impact other resources. This activity will also satisfy IA_BE_13.
  • IA_PM_16 – Implementation of Medication Management Practice Improvements – While there are several ways to satisfy this activity, the AUA recommends that urologists do so through medication reviews or reconciliation. This activity can also be used for IA_PM_13. CMS recommends that participants implement the AHRQ Create a Safe Medicine List Together” strategy.
  • IA_CC_1 – Implementation of use of specialist reports back to referring clinicians or groups to close referring loop – There are two ways to satisfy this activity and both involve documenting reports in the patient’s file. If you are referring patients to other providers, note that in the patient’s chart and make sure to document any reports or results the other provider sends you. Likewise if patients are referred to you, note that in the chart and make sure to document that you provided reports and/or results to the referring provider. This activity also satisfies IA_CC_12.
  • IA_CC_2 – Implementation of improvements that contribute to more timely communication of test results – This activity requires that you contact any patient that has an abnormal test result and that you document the result and how and when you contacted the patient, which could be by mail, phone call, etc. CMS does not define “timely,” but most offices already have a working definition of this.
  • IA_CC_7 – Regular training in care coordination – A practice must have “documentation of implemented regular care coordination training within practice.” However, this is very open. There are many organizations that offer care coordination resources, such as the Agency for Healthcare Quality and Research’s webinar series entitled TeamSTEPPS. The webinars also are archived so they can be viewed whenever it is most convenient. Whatever program you decide to use, keep validation of registration/participation in the event. Your practice (or at least a quality improvement team) should discuss the content of the webinars and implement what is feasible. CMS stresses that the main goal of this activity is to meet patients’ needs. Thus, there should be some mechanism for gathering this information. CME and other forms of accreditation often are offered for these webinars and training sessions.
  • IA_CC_12 – Care Coordination agreements that promote improvements in patient tracking across settings - If you are referring patients to other providers, note that in the patient’s chart (either paper or electronic) and make sure to document any reports or results the other provider sends to you. Likewise, if patients are referred to you, note that in the chart and make sure to document that you sent reports and/or results to the referring provider. This activity also satisfies IA_CC_1 and possibly IA_CC_13.
  • IA_CC_13 – Practice improvements for bilateral exchange of patient information - One aspect of this activity is the use of structured referral notes, and the other is health information exchange (this can be between healthcare providers or providers and patients). Check with your electronic health record (EHR) vendor to verify the best way to include referral notes. If you are using electronic health information exchange, confirmation (such as email confirmations or screenshots) is needed to satisfy this activity. This activity can also be set up in such a way that it would also satisfy IA_CC_1 and IA_CC-12.
  • IA_BE_6 – Collection and follow-up on patient experience and satisfaction data on beneficiary engagement – If you are using a patient survey administered by a third party survey administrator/vendor (as discussed in IA_EPA_3 and IA_BE_13), you can satisfy this activity by taking it to the next level. For example, your practice could follow up with patients to address any concerns they might have, or, your practice could use this information to design an improvement plan. The plan does not need to be implemented at this stage, but there must be concrete evidence that you have administered a patient survey and then drafted improvements based on the survey’s results.
  • IA_BE_13 – Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms - This activity focuses on collection feedback from your patients and then using information to implement change in your practice. CMS recommends that the surveys be administered independently. This activity will also satisfy IA_EPA_3.
  • IA_BE_15 – Engagement of patients, family and caregivers in developing a plan of care - To complete this activity you could utilize an advanced care plan or a plan specific to the urological treatment you are providing. While you probably do not need all the information that would be noted in an advanced care plan, it is good information to have in the patient’s file. Many patients already have such plans; so, it is merely a matter of obtaining it and putting a copy in the file. In order to satisfy this activity, you must produce a report from your electronic health record showing the plan of care and engagement/inclusion of the patient, family, and/or caregivers. Doing this activity would satisfy IA_PM_13, and IA_CC_9.
  • IA_BE_21 – Improved practices that disseminate appropriate self-management materials – The Urology Care Foundation (the official foundation of the AUA) has created self-management materials on numerous urologic conditions that can be provided to patients. To satisfy this activity, you must document in the patient’s record what materials were distributed, as well as any accompanying instructions or results.
  • IA_PSPA_3 – Participate in Institute for Healthcare Improvement (IHI) training/forum event; National Academy of Medicine, AHRQ Team STEPPS or other similar activity – Many national organizations, including the AUA, offer seminars and events focused on quality improvement and patient safety, and participating in one (either in-person or online, and some free of charge) would satisfy this activity. The AUA offers the Quality Improvement Summit. Check the websites of other organizations (such as ihi.org, nam.edu, or ahrq.gov/teamstepps) for their offerings throughout the year.
  • IA_PSPA_4 – Administration of the AHRQ Survey of Patient Safety Culture – All employees of the practice would need to complete this survey and results must be submitted to AHRQ. AHRQ provides a user’s guide, as well as the form to help with its administration. At this point, CMS does not require any analysis of the results or follow-up on the survey. So, simply completing and submitting would be an inexpensive and quick way to complete an activity. This activity can only be done once every four years.
  • IA_PSPA_8 – Use of patient safety tools – The surgical risk calculator [such as the one available through the American College of Surgeons (ASC)], the International Prostate Symptom Score (IPSS), or AUA Symptom Index (AUA-SI) are widely used patient safety tools in urology. If you already use one of these or plan to start, document this act in a patient’s chart when appropriate in order to satisfy this activity. The ASC surgical risk calculator is also available on the AUA Guidelines app. The AUA’s white paper series on Optimizing Surgical Outcomes also highlights a variety of tools such as ERAS protocols, nutrition assessment tools, etc. Quality measure #476 also pertains to the IPSS and AUA-SI.
  • IA_PSPA_9 – Completion of the AMA STEPS Forward program – The STEPS Forward program is an online initiative geared at improving practice efficiency as well as improving care and the patient experience. This tool can be used at your convenience and allows you to customize your educational experience by focusing on both clinical and practical modules. In additional to obtaining a certificate of completion for at least one AMA STEPS Forward module, participants must have documentation that they have implemented what they learned into their processes of care. CME is available for some modules. Start by watching the overview video.
  • Participation in a Qualified Clinical Data Registry (QCDR) – Many activities may be achieved through QCDR participation. The AUA offers the AQUA Registry, which is a CMS-approved QCDR. AQUA can also be used to complete the Quality reporting program and satisfy some aspects of Promoting Interoperability. For more information, contact AQUA@AUAnet.org or 855-898-AQUA (2782).

Disclaimer: The AUA encourages practices to download and review CMS’ improvement activity (IA) data validation requirements. Providers should maintain documentation supporting the compilation of each activity, in the event of a future CMS audit. Additionally, the AUA and AQUA Registry cannot guarantee a positive/negative payment adjustment at any time.

Calculating the Final Score for the Improvement Activities Performance Category

As noted earlier, each IA is worth either 10 points or 20 points (although the point values may be higher for some participants), and the maximum number of points possible for the IA category is 40. Participants can select whatever combination of activities they desire to reach those 40 points. Again, they must engage in those activities for at least 90 continuous days, unless otherwise stated in the activity description. The IA performance category accounts for 15 percent of the overall MIPS score.

As an example, if a participant implemented 2 medium-weight activities and one high-weight activity, their IA performance category percent score would be (10+10+20)/40=100 percent. Note, however, that a participant cannot earn more than 100% for this performance category (even if they attest to implementing additional improvement activities).

The formula for determining the total points for the Improvement Activities category is: (IA performance category percent score) x (IA category weight) x 100.

Using the example above, the Improvement Activities score would be: 100 percent x 15 percent x 100 =15 points.

Performance Category: Promoting Interoperability

The goal of the Promoting Interoperability (PI) performance category is to foster the electronic exchange of health information using certified electronic health record technology (CEHRT). Use of technology to exchange and make use of information (i.e., interoperability) reduces burden associated with communicating patient information and, by extension, improves patient access to their health information, information exchange between clinicians and pharmacies, and the systematic collection, analysis, and interpretation of healthcare data. In 2021, the weight for the PI performance category is 20 percent (that is, this category accounts for 25% of the total MIPS score).

The PI category focuses on 4 objectives:

  • e-Prescribing
  • Health Information Exchange
  • Provider-to-Patient Exchange
  • Public Health and Clincial Data Exchange

All participants must use 2015 Certified Electronic Health Record Technology (CEHRT), technology certified to the 2015 Edition Cures Update certification criteria, or a combination of both. Participants should check with their EHR vendor if unsure of their CEHRT version.

Participants can report as an individual or a group, either directly or through a third party, such as the AQUA registry. Some participants may be automatically exempted from this performance category (based on special status or clinician type), and others may qualify for a hardship exception (small practice, using decertified EHR technology, insufficient internet connectivity, or lack of control over CEHRT availability). This exception results in the re-weighting of the PI category to zero. Those who are not automatically exempted must apply for the exception. Even if a participant received an exception previously, they must apply again in 2021.

PI Measures

For the PI performance category, participants must report on either 5 or 6 required measures. Data for these measures must be collected during the same continuous 90-day period (or more) during the calendar year.

In addition to the PI measures, participants must provide their EHR’s CMS Identification code from the Certified Health IT Product list and submit a “yes” to the following three requirements:

  • The Prevention of Information Blocking Attestation
  • The ONC Direct Review Attestation
  • The Security Risk Analysis measure

Infomation about the PI measures is shown below.

Objective Measures Maximum Points
e-Prescribing e-Prescribing 10 points
Query of Prescribing Drug Monitoring Program (PDMP) 10 bonus points
Health Information Exchange Option 1: Support Electronic Referral Loops by Sending Health Information and Support Electronic Referral Loops by Receiving and Reconciling Health Information 20 points each
Option 2: HIE Bi-Directional Exchange 40 points
Provider to Patient Exchange Provide Patients Electronic Access to Their Health Information 40 points
Public Health and Clinical Data Exchange Report to two different public health agencies or clinical data registries for any of the following:
  • Immunization Registry Reporting
  • Electronic Case Reporting
  • Public Health Registry Reporting
  • Clinical Data Registry Reporting
  • Syndromic Surveillance Reporting
10 points

The specifications for the measures are posted on the CMS QPP website.

  • e-Prescribing (10 points) – This measure tracks the number of prescriptions sent electronically compared to the total number of prescriptions. Clinicians can determine if they wish to include controlled substances in this measure; however, the decision must be uniformly applied. Clinicians or groups who prescribe 100 or fewer permissible prescriptions overall will be excluded from this measure. If that happens, the 10 points for this measure will be redistributed equally to the two Health Information Exchange referral loop measures.
  • Support Electronic Referral Loops by Sending Health Information (20 points) – For this measure, a clinician must transition or refer a patient to another setting of care or healthcare provider. In the process, the clinician must create a summary of care using their EHR and electronically exchange the summary of care record. There must be a reasonable certainty of receipt by the receiving clinician (e.g., receipt conformation or query about the information sent). Performance is determined by calculating the ratio of the number of transitions or referrals where a summary of care record was created and exchanged electronically to the total number of transitions and referrals. If a clinician or practice has fewer than 100 transfers or referrals during the performance period, an exclusion can be claimed. If the exclusion is granted, the 20 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure.
  • Support Electronic Referral Loops by Receiving and Reconciling Health Information (20 points) – To satisfy this measure, the clinician or group who receives a referral or transition of care must conduct a clinical information reconciliation for medication (name, dosage, frequency, and route), medication allergies, and current problem list. The key to this measure is not the referral itself, but rather the reconciliation of the clinical information into the new practice’s EHR system. An exclusion can be granted if a clinician or practices does not receive at least 100 referrals/transitions during the performance period. In that case, the 20 points would be transferred to the other referral loop measure.
  • Health Information Exchange (HIE) Bi-Directional Exchange (40 points) – This is not a required measure unless it is being submitted as an alternative to the two referral loop measures. This measure allows an eligible clinician or group to attest to participation in bi-directional exchange through an HIE using CEHRT functionality to support transitions of care. The eligible clinician must attest that 1) they participate in an HIE to enable bi-directional exchange for every patient encounter, transition of care/referral, and record 2) the HIE is capable of exchanging information across a network of unaffiliated exchange partners and 3) they use the CEHRT to support the bi-directional exchange with an HIE.
  • Provide Patients Electronic Access to their Health Information (40 points) – This measure has two parts. First, the clinician or group must provide patients timely access (defined as within 4 business days) to view online, download and transmit the patient’s health information. Second, the clinician or practice must ensure that the patient’s health information is available for the patient (or the patient’s representative) to access using any application of their choice as long as it meets the technical specifications of the Application Programming Interface (API) in the provider’s EHR. Most providers satisfy the second requirement via a patient portal, but there are other options as well. There is no exclusion for this measure. The performance for this measure is determined by calculating the number of patients who have access to their health information with the two requirements listed above, compared to the total number of patients seen during the performance period.
  • Public Health or Clinical Data Registry Reporting (10 points) – This measure requires active engagement with public health or clinical data registries. CMS defines “active engagement” as one of the following three: completed registration and preparing to submit data, testing and validating the submission of data, or submitting production data (not test data). Reporting to the AUA’s AQUA Registry would qualify as Clinical Data Registry Reporting. Reporting to the National Ambulatory Medical Care Survey is a free option for satisfying this measure. If exclusions are granted for this measure, the 10 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure. A clinician or group may be excluded from the measure for any one of the following reasons:
    • Does not diagnose or directly treat any disease or condition associated with a public health or clinical data registry in their jurisdiction during the performance period
    • Operates in a jurisdiction for which no public health or clinical data registry is capable of accepting electronic registry transactions in the specific standards required to meet the CERHT definition at the start of the performance period
    • Operates in a jurisdiction where no public health or clinical data registry for which the MIPS clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.
  • Query of Prescription Drug Monitoring Program (PDMP) – This remains an optional measure worth 10 bonus points. If a participant decides to report this measure, they must do so through attestation. There is no case minimum for this measure. As long as a clinician conducts a query of a PDMP for prescription drug history before prescribing a qualifying Schedule II opioid using CEHRT, the measure is satisfied.

Note that all PIs must begin no later than October 3, 2021 (in order to have a full 90-day performance window). As with the Improvement Activities performance category, documentation supporting PI reporting is not required at the time of attestation. However, documentation should be compiled, and would be required in the event of a CMS audit. Participants must keep this documentation for six years after attestation. Requirements for this documentation can be located on the CMS QPP Resource Library webpage.

Calculating the Final Score for the Promoting Interoperability Performance Category

Participants can earn 100 measure points based on results of required measures, with the option to earn 10 bonus points. Claiming an allowed measure exclusion causes the measure’s points to be shifted to a different measure. If a participant does not report either a numerator of at least one or a “yes” for a required non-bonus measure, or claim an exclusion for a required measure, then they will receive a score of 0 for the entire category. Additionally, an annual security risk analysis must be conducted and reported, as does the Prevention of Information Blocking attestation and the ONC Direct Review attestation. If not, a score of 0 will be awarded for the category.

Points for each measure are earned depending on the type of measure. Measures with a numerator and denominator receive points based on their results, which are multiplied by the maximum number of points available for the measure. As an example, if a participant is has a 75% performance for the Provide Patients Electronic Access to Their Health Information measure (which is worth a maximum of 40 points), they would earn 30 points (0.75*40) towards the PI performance category. Attestation measures where the participant responds “yes” receive the maximum number of points available for the measure.

To calculate the final percent score for the PI performance category, sum the points earned for each measure and divide by 100. Note, however, that the score is capped at 100 percent. The formula to determine the total points for the PI category is: (PI performance category percent score) x (PI category weight) x 100.

As an example, if the final percent score for the PI category is 92 percent, the final Promoting Interoperability score would be: 92 percent x 25 percent x 100 =23 points.

Calculating the Final MIPS Score

The final MIPS score is calculated by adding together the final scores for each of the four performance categories, along with any “complex patient” bonus points earned.

CMS recognizes the challenges and costs incurred by clinicians for caring for complex patients. Therefore, CMS will analyze participant data to determine the number of bonus points (if any) for complex patients. The bonus is based upon Hierarchical Condition Category (HCC) risk scores that incorporate age, gender, and diagnoses from the previous year (to determine medical complexity) and the proportion of patients with dual Medicare-Medicaid eligibility (as a proxy for social risk). Up to 5 bonus points may be awarded, depending on the level of clinical complexity and social risk. The complex patient bonus will be granted only if data are submitted for the quality, improvement activities, or promoting interoperability performance categories.

From the examples shown above, the performance category scores were:

  • Quality: 30 points
  • Cost: 13 points
  • Improvement Activities: 15 points
  • Promoting INteroperability: 23 points

Assume this participant also earned two complex patient bonus points. Thus, the final MIPS score would be: 30+13+15+23+2 = 83 points. As noted earlier, this score is high enough to earn a positive payment adjustment (i.e., 60 or more points needed). However, it is not quite high enough to earn the “exceptional performance” bonus (i.e., 85 or more points needed).

Additional Information

Due to the COVID-19 public health emergency, CMS has extended use of the Extreme and Uncontrollable Circumstances Hardship Exception through 2021. This allows eligible clinicians to apply to have one or more MIPS performance categories to be reweighted. Also, given the expansion of telehealth services due to the COVID-19 public health emergency, CMS has incorporated applicable telehealth services into the MIPS Cost measures.

CMS has developed extensive descriptions for, and detailed documentation of, the requirements and operation of the MIPS program. These are available on its QPP website. A few of the most helpful resources, available through this site’s Resource Library, include:

2021 MIPS Quick Start Guide
2021 Eligibility and Participation Quick Start Guide

2021 Quality Quick Start Guide
2021 Quality Benchmarks

2021 Cost Quick Start Guide
2021 MIPS Summary of Cost Measures
2021 Cost Measure Code List

2021 Improvement Activities Quick Start Guide
2021 Improvement Activities Inventory

2021 Promoting Interoperability Quick Start Guide
2021 Promoting Interoperability Measure Specifications

Note that CMS may add additional documents to this resource library or update the documents throughout the year.

Finally, other sources of information regarding MIPS include the following:

CMS Quality Payment Program Help Desk
Phone: 866-288-8292
E-mail: QPP@cms.hhs.gov

AUA Quality Department
E-mail: quality@auanet.org