Sept. 6, 2024: National Advocacy Update

Physicians have an opportunity to provide feedback directly to the Centers for Medicare & Medicaid Services (CMS) to help improve the final Merit-based Incentive Payment System (MIPS) feedback process. Participation in the survey is voluntary and confidential.

The survey should take no more than 15 minutes to complete, and results will be reported in such a way that no single individual, group or entity can be identified, and MIPS-eligible clinicians who complete it will receive an Improvement Activity credit. Physicians can now access their final 2023 MIPS scores and payment adjustments by signing into the Quality Payment Program website. 

The AMA has strongly urged (PDF) CMS to improve the frequency and usefulness of the MIPS data shared with physicians and to resolve discrepancies in the MIPS public use files. Currently, for all MIPS cost measures, as well as the administrative claims-based quality measures, CMS calculates these metrics on the back end using claims data. As a result, physicians have no information about the patients attributed to them, which measures they are being assessed on, or their performance until six months after the performance period.  

Without this information at any point during the actual performance year, physicians have no way to monitor their performance, identify opportunities for efficiencies in care delivery, and avoid unnecessary costs. The AMA has recommended that CMS make Medicare claims data and meaningful MIPS attribution, measure, and performance data available on a rolling basis, or at a minimum, on a quarterly basis during the actual performance period, which CMS is required to do by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. 

In response to numerous questions raised by the AMA, physicians and national medical specialty societies, CMS has released much-anticipated frequently asked questions (FAQs) (PDF) about the Evaluation and Management (E/M) Visit Complexity Add-On HCPCS Code G2211. Regarding whether the add-on code can be billed when a patient sees another physician or practitioner in the same group practice, CMS provides this may be appropriate depending on whether the patient sees another physician or practitioner in a team-based care practice and if all other requirements to bill G2211 are met. CMS clarified that G2211 can be billed for services furnished under the primary care exception in teaching settings. Regarding documentation, the agency expects information included in the medical record or in the claims history could serve as supporting documentation for billing G2211. The FAQs address several other topics, including what constitutes a serious or complex condition and the application of patient cost-sharing. 

The AMA urges all physicians and practices to log into the CMS Quality Payment Program (QPP) portal to review their final 2023 MIPS performance year scores. If you believe there is an error in the calculation of your MIPS score or accompanying payment adjustment for the 2025 payment year/2023 performance year, you can request a targeted review now until Oct. 11, 2024, at 8 p.m. Eastern. 

For example: 

• Data submitted under the wrong TIN or National Provider Identifier (NPI) 
• You have Qualifying APM Participant (QP) status and should not receive a MIPS payment adjustment 
• Performance categories were not automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances 

This is not a comprehensive list of circumstances. If you have questions about whether your circumstances warrant a targeted review, please contact the QPP Service Center by phone at 1-866-288-8292 (TRS: 711) or by email at [email protected].   

How to request a targeted review: 

Physicians can access their MIPS final score and performance feedback and request a targeted review: 

• Sign in using HARP credentials (ACO-MS credentials for Shared Savings Program ACOs); these are the same credentials that allowed submission of 2023 MIPS data. 
• Click “Targeted Review” on the left-hand navigation. 

CMS generally requires documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required. If the targeted review request is approved and results in a scoring change, CMS will update the final score and/or associated payment adjustment (if applicable), as soon as technically feasible. Please note that targeted review decisions are final and not eligible for further review. 

Targeted review resources: 

• 2023 Targeted Review User Guide (PDF)—Reviews the process for requesting a targeted review and examples for when you would or wouldn’t request a targeted review. 
• 2025 MIPS Payment Year Payment Adjustment User Guide (PDF)—Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions. 

Starting Jan. 1, 2025, Medicare Accountable Care Organizations (ACOs) must start reporting MIPS Promoting Interoperability (PI) data for all participating practices, regardless of Advanced APM status. The Certified EHR Technology (CEHRT) utilization threshold for Advanced APMs will also increase from 75% of eligible clinicians to “all” eligible clinicians. Since both policies were finalized last year over opposition from the AMA and others, the AMA has pushed for flexibilities that will help to mitigate the burden of both policies on Advanced APM participants.   

The Centers for Medicare and Medicaid Innovation (CMMI) recently clarified in new guidance (PDF) that ACOs must report MIPS PI data to be eligible to share in savings but that an ACO’s PI score would not impact shared savings calculations. In response to AMA advocacy, CMMI also clarified that clinicians in small practices will be excluded in addition to non-patient facing clinicians, hospital-based clinicians, and clinicians based in Ambulatory Surgery Centers. In separate guidance, CMMI clarified that REACH ACOs will attest to participant provider use of CEHRT for at least one quarter of 2025 (as opposed to the full year) or qualify for an exclusion to allow additional time to achieve compliance. AMA continues to warn CMS that more information is desperately needed as ACOs and other APMs finalize participant lists ahead of 2025. The AMA also continues to push for additional flexibilities and a corrective action-based compliance approach to minimize disruptions next year. Additional guidance on both policies is said to be forthcoming. 

• Sept. 6, 2024: State Advocacy Update