Okay, can everyone see my screen okay? Yes. Perfect. Well, good afternoon, fellow AAOE members and any guests out there. I personally have been involved in quality reporting of some type since 2012, and I still don't consider myself an expert. My approach has definitely evolved over time, and I hope to offer you all some takeaways to assist you in managing quality reporting in your practice. Now as Jessica said at the beginning, please post any questions you have in chat, and I will try to answer questions as we go, but then we'll also have a Q&A at the end. I have about 35 minutes of content, so that should allow plenty of time for Q&A. So let's get started. So the first lesson that I have learned since reporting MIPS is that it is definitely a project. Now who remembers the days back in 2017 when we first reported MIPS, and you could literally pick any six measures and report and avoid a penalty, because you only needed three points to avoid a penalty. Well, it's gotten a lot more complicated, hasn't it? And we really have to work at it to avoid a penalty. So my approach is to run it like a regular IT project. I form a QPP team, which is made up of myself, an application specialist, and then some of the practice management staff, and we go together and we select the measures together. Also the improvement activities. Now one of the reasons for that is because I personally can't hold people accountable in my position for documenting quality measures, but the management can. And so if I have their buy-in, then I know that we're all starting in the same place and have the same goals in mind. So we do select all those measures as a team, then we schedule out who's doing what, and we set deadlines. So who's responsible for training? Who's responsible for following up with staff and letting them know how they're doing, giving them feedback reports? Who's communicating with the physicians, letting them know how we're doing in the MIPS program and how it's going to impact their paycheck? We have a communication plan in place, like I said, giving feedback to the staff. And then we do meet regularly to see how our progress is going. Nothing is worse than getting to the end of the reporting year and finding out your points are a lot lower than what you expected. Lesson learned number two, educate yourself. This is so critical because we know that the rules in this game of MIPS change every single year. So the Quality Payment Program website is my Bible for all things QPP. I suggest that you subscribe to the listserv. So the picture on my slide shows you where you can do that on the QPP website. And make sure you check regularly for new content that's available. Anything that I hear or read or learn that doesn't come from CMS, I validate on this website. So I think it's great that you're attending this webinar today. And if there's any question about can you show me where that data comes from, feel free to reach out to me on Collaborate and I'll happily give you the QPP documents. Because without that proof, if you go to report or trust something that somebody else tells you, you could be in a bad position. So my first question of engagement with the attendees today is, have you ever trusted an outside source only to find out that some of the information they gave you was wrong? So go ahead. If you want to post something in chat, you can do that. And I can definitely tell you that early on when I was reporting for Meaningful Use, I listened to a webinar from some consultant. And some of the advice they gave was really bad. And that's where I learned my lesson that you really need to validate the information and make sure that it matches up with what CMS, how they run the program. So do we have any comments at all? Addie? I don't see that anything has come in yet. But definitely feel free if you are in the midst of typing, drop it in. I think that's interesting to hear if anybody else has had similar experience. And we can always touch on those at the end as well. Perfect. So my third lesson is pay attention to the details. And I am associating this specifically with reporting quality measures and selecting quality measures. There are a large library of measures to choose from. And there's a lot of considerations when selecting those measures, whether you're reporting straight MIPS or the MIPS value pathway. Some of the things that I look at when we are selecting measures for the current year is which measures are my EMR certified to report? Then what is the workflow to get credit for those measures? Is it something that staff is already doing in the EMR? Or are they going to have to learn a new workflow? What it comes down to is are there going to be more clicks, right? So we want to know that. We want to know how much work it is. And then if my EMR doesn't report that measure and I have to use maybe a QCDR to report, which is a registry that you can use to report measures, what is it going to take to collect the data to be able to report that measure? Are you going to have to have an interface? Again, is there going to be a lot of other steps? And is there going to be a collection process that takes place outside the EMR? All those need to be considered. Also, if you decide to participate in the MIPS value pathway, you know there's a much smaller subset of measures that you have to choose from. So you want to make sure that there's a minimum of four measures that you feel comfortable, you know, collecting data on and reporting. You might want to look if you have a choice of administrative measures in your MVP. Is that something you're interested in? Keep in mind those administrative claims measures, you're not going to have any idea how you're doing on that measure. You are just taking a gamble of whatever it ends up being when you get your score at the end of the time period, at the end of the year, actually in July after you've reported. You want to make sure that it is a measure that you can meet the minimum denominator of at least 20 patients. You want to make sure that you have at least one outcome or high priority measure. Now, also, one other thing to be aware of is in October, when ICD-10 releases their new codes or maybe sunset some codes, that can sometimes impact the measures that you're reporting. So it's important to be aware of that. It may not impact your selection of measures, but you do want to be aware of it and watch for that come October, which is another reason to sign up for the listserv so you're aware of that. Now, I also would like to talk about when you're selecting measures, thinking about what is the possible score that you can get because no one wants to spend a whole year collecting data on a measure that you can't earn any points. So I am going to show you a snapshot of the MIPS or CMS benchmark Excel spreadsheet that you can get from the QPP website. And we're just going to go through a few examples so you know what to look for as far as what is your possible score or what is going on with the measure that would impact my score. So on the screen, the first measure set that I have, or first two measures, is the osteoporosis management in women who had a fracture. And what I would like to call your attention to on this specifically is that under this column, does the measure have a benchmark? One of the versions of the measure does not have a benchmark. Okay? So if you report it via Medicare Part B claims, there is no benchmark. Now, if you report it as a MIPS CQM, it does have a benchmark. And if I scroll all the way over, you can see in the column of comments, it says there was insufficient volume in 2023 to have a benchmark. So you're not going to want to report this measure unless you want zero points. Okay. Next example, closing the referral loop. So this one is interesting. There are two different ways of reporting it. You can report it as a MIPS CQM or as an eCQM. And the score you get, though, really varies depending on those two methods. So if I scroll over and look at the performance, I can see that the first version, which is the MIPS CQM, is a topped out measure. So it means that it's capped. And next year, it will get a max of seven points. But basically, you have to have a really, really high performance to be able to get a very good score. Whereas on the other version of reporting, the eCQM version, I can have a 65%. And I can still get eight points for that measure. So you want to really review this spreadsheet. Another common thing that I see, so I talked about topped out measures. Here's the fall plan of care measure in green. Now it's only available in one way of reporting or collection type, which is a MIPS CQM. But if we scroll over, we can see that it's a topped out measure and it's capped at seven points. So I would have to get 100% just to get seven points. And if I get 98%, I'm only getting two points on that measure. Now I have the adult COVID-19 vaccine measure on here. And this is the one exception to does the measure have a benchmark or not? This one does not have a benchmark, but that is because it is a brand new measure. It says that the measure was added this year, 2025. And so there is a seven point scoring floor if you meet the data completeness for this measure. So don't automatically discount a measure because it doesn't have a benchmark. Make sure you read all the comments about the measure. And then the last point that I would like to bring up is measures that have multi performance rates. And so I have on here the tobacco measure, and I would venture to guess that most of your practices have reported on this measure at least once in the duration of MIPS. So on multi performance measures, there is a special spreadsheet again on the QPP website that goes over these measures and it tells you what you're actually scored on. Now currently on the tobacco screening measure on this spreadsheet, you can see that it says the benchmark is based on the second performance rate. So that is the part of the measure where the patient was a tobacco user and it's counting the number of patients that you provided some type of cessation counseling to during the reporting period. So you could have only screened 80% of your patients, but if you provided intervention with everybody that was positive for use of tobacco, then you could get 100% on the measure and maximize your points. So my point is just make sure if it's a multi performance rate measure, you know which of the rates you're being scored on for your measures. Now I know that was a lot of data to go over. So if you have any questions, go ahead and post those in the chat. And I can either answer them now or we can tackle them at the end of the presentation. let's go on to the next lesson learned, and that is to start early. Now I think this applies to all of the Quality Payment Program and VIPS, but specifically I called it out for promoting interoperability. And the reason I did that was because we used to only have to report promoting interoperability for 90 days. And that changed last year in 2024. You now have to report for 180 days. And what that means is if there is a new technology, because you have to be on the certified version of your software for the full 180 days, if there's a new version, you have to allow time to take that upgrade so you're ready for that full reporting period. So that's why I say start early and make sure you're aware of the version you need to be on and what the steps are to get your software updated for that. I did want to call out a few other things that have recently changed in promoting interoperability or that I'd like to call your attention to. So the SAFER Guide, the High Priority SAFER Guide, that is not new, but with 2024, that was the first year that we were required to actually fill out the SAFER Guide. Prior to that, you could just say yes or no if you did it and you passed. Well, now you have to do the SAFER Guide. And now there has been a new release of the SAFER Guide. There's a new version. And interesting enough, the CMS measure paper for the SAFER Guide for 2025 still references the old version of the SAFER Guide. It references the version from like 2016. So you will want to find out if you can use the new one. And I'll talk about that at the end, what you can do to find out if you can use the new version or if you have to use the old version. Another item I'd like to recommend is that the Prescription Drug Monitoring Program is a measure that we are only attesting yes or no, did we do it? We don't have to report a numerator and denominator. And we all know that we can be audited for what we report to MIPS. And so I strongly recommend that you are capturing some type of documentation showing that your physicians are really checking a Prescription Drug Monitoring Program, whether that be integrated through your EMR or a separate application that they're logging into to check that. The HIE measures, you have a couple of different options of how you can report those. If you report on the two individual measures, the sending and importing of electronic referrals, you are reporting a numerator and denominator for those measures. You have a second option to attest to using bidirectional capabilities for that measure. Again, interestingly, if you do the bidirectional, you are not reporting a numerator and denominator. You're just saying, yep, we do bidirectional. So again, I highly recommend that if you do the bidirectional or the TEFCA version of this measure, that you maintain some type of documentation proving that you really are doing this. On the public health measures and the clinical data exchange, now there's two measures that are required, and that's immunization reporting and electronic case reporting. Now, I know a lot of you, if you're just a straight orthopedic practice, you can probably exclude from the immunization measure. With the electronic case reporting, you would need to check with your state to see if they have any diagnoses that they're accepting case reporting on that you actually treat. Now, don't assume that because in 2024, they didn't have any relevant diagnoses that they wanted you to report that it's the same for 2025. You need to recheck each year to see if you meet the criteria to be able to exclude from the measure, and make sure you maintain documentation on that. Anytime you're excluding from a measure in the promoting interoperability portion of MIPS, it causes a reweighting of the measures that you are reporting. So keep in mind that that will happen, and you don't have to exclude from something if you're actually doing it. So what do I mean by that? In the case of e-prescribing, if you have a provider and you're reporting individually, and that provider only has 90 e-prescribes, their denominator was 90, you can exclude from e-prescribing. But if you're performing at a really good rate, why would you? The same with the HIE measures. If you are not receiving any referrals, but you're sending referrals, but you only sent 80 referrals, and your denominator is maybe 82, you probably have a really good performance rate. And so don't automatically exclude just because you can exclude. So that's kind of my little tip there. You know, do the math and figure that out. And then I did want to also mention that those public health measures that you can earn bonus points on, I don't know if you're aware, but the Center for Disease Control has an option that you can register to do public health surveys, and you can earn credit for reporting to a public health registry. Now, one thing to be aware of that CMS changed in 2024 is they came along and said that you can only report pre-production and validation for interface one time. You can only do it the first year. In the past, you could just say, I'm still in pre-production, I'm still engaging, but I don't have an interface live. Well, they've cut it off, and they've said, if you do it in 2024, that means in 2025, you have to be live. So definitely be aware of that and be on top of that if you are not finished getting your interfaces in place, if you are trying to do some of this additional public health reporting. Hey, Debbie? Yes. We have something in the Q&A, and I think you might have a slide coming up on that, but because it just came in, I thought I would pose it to you. Nicole's wondering if you can explain what you know about the cost category, because they don't have a lot of knowledge surrounding this. Is that going to be covered on that slide? Yeah, I do have a slide, and I am going to talk a little bit about cost, yes. Great. Thank you so much. Sure, sure. So one thing I wanted to pose to all of you is to not hesitate to reach out to CMS via the Quality Payment Program Help Desk if you need clarification. And the reason I bring this up is just because of that SAFER Guide I talked about earlier. I got a notification that there was a new version of the SAFER Guide, but then I went and read the white paper on the measure, and it was still referencing the old SAFER Guide. So I sent a message to QPP and asked them, does it matter which version we use, or should we use only the version they recommended in the white paper? And of course, I got a really big answer, so I will be sending another question for clarification. But don't hesitate to reach out to them. And then when you get those responses, hold on to that documentation if anything is ever in question again, because that's your proof that this is what CMS told me. Okay, next lesson. Debbie, really quick, do you mind projecting a little bit more? Okay, sure. Thank you. So the next lesson is go with the flow. And I like to think about this in relation to improvement activities. Now, some of the improvement activities that probably a lot of your practices have been doing, like the 24-7 access, that one actually went away for this year, for 2025. And then the other popular improvement activity of sending referral letters back to the referring physician, that measure, or that improvement activity, is going away in 2026. So your practices may have to review improvement activities again and find something new. Now, on a bright note, they have done away with the weighting of improvement activities. There is no longer a medium and high-weighted activity, and you need so many of each. They're just all equal. And if you're reporting MIPS, you need two activities. And I believe in MVP, you just have to select one of the improvement activities in the MVP. But that being said, I recommend selecting an activity that either fits within the workflow of what you're already doing in your practice, or maybe something that helps solve a problem in your practice and that you can earn points for. So one example that our office is contemplating doing this year, we get a ton of calls asking our medical records department to send office notes to the patient portal. We don't have a feature that just automatic, we don't have it turned on where it just automatically sends all notes. So there is an improvement activity called Open Notes, and that is what we are looking at doing as one of our improvement activities this year. Now, make sure on your improvement activities that you're not just reading what the activity is, but what are the documentation requirements to get credit. And you have to do that activity for at least 90 days. Okay, next lesson learned. This is probably pretty common sense, but you have to think about what can I do to help get our scores better? What can I do to give feedback to the people who are documenting the measures? And I think it's important that you find a way to give that constant feedback to the staff so that they can react in a positive way instead of going back to them after you've been doing quality measures for six months and saying, hey, did you realize that your fall screening score is like 15%? So what we have done in the practices that I'm working with that are part of Signature, we do QPP training every year. Whether people have been doing the same measures or not, we just go through a refresher every year. We give the staff, the clinic staff mainly, a list of the measures that they're responsible for documenting and what the target percentage performance is that we want them to meet. We give them a report card each month. So on this slide is a tiny snapshot of the report card we give out. And it shows them what their current performance is and how and in relation to how much have they increased or decreased from the previous month and then what their goal is. And so it is very clear to them how they are performing. And there's no surprises like halfway through the year or at the end of the year trying to recover from poor performance. Now another option, because we use all measures through our electronic health record, we create, we run treatment opportunity reports. And what that is, is basically a list of patients who are subject to a particular measure, but they're not, they haven't documented the measure. And we give it back to the staff who were responsible for documenting it. And we started that last year and that was a real game changer for our performance. Because the people who were missing it had to go back and fix it. They got a lot more consistent with documenting the measure going forward. And we got some of the best quality scores last year that we ever have with that process. And you know, maybe you can find a way to actually gamify it in your practice. You can post everybody's scores. We don't do that in our practice. But I know when we pass out the treatment opportunity reports, people are always like on the edge of their seat. Do I get one this month, this week? Or did I do good? It's like you just have one, you just missed one fall screening last week. So it's kind of fun and the people enjoy seeing how their progress is. Now, I would like to, you know, ask all of you at minimum, please post in chat. What do you do in your practice to get the best possible quality scores that you can? Do you have some other strategy that you follow? And you know, do you have any incentive program that you do for those scores. And if you if there are any you can read them off to me or we can talk about it at the end, but at least share them with your, your fellow attendees. Okay, the next slide or lesson learned that I'd like to talk about is controlling cost. And this is such a tough category because we feel pretty helpless we don't really have specific action items that we can take. And we have no idea how we're doing until until the game is over right and we get that final score and you know you're on your edge of your seat did I get enough points to avoid the penalty. So I have a few suggestions. Number one, be familiar with the measures that are applicable to your practice. So on this slide I listed, probably some of the most common measures of common cost measures that would be applicable to most orthopedic practices, but I encourage you to, you know, download the QPP data and read through all of them because you may offer some services that you know other practices don't or you may be multi specialty. So know those measures and understand how they're scored so you kind of know how you're impacted. Now a lot of those measures are episodic they're based on a on a specific procedure being done. Then the question is, what can I do to improve my cost score. So one thing you can do is when you get your cost data from the year before, two years before almost by the time you get it, read through it and really look at the data and see why did I get dinged Why was my score so low. And, you know, where were my expenses higher kind of look at that. Some of the things that generally can help in orthopedics would be implementing some type of case management or care coordination, especially for the episodes that you know are scored. would be avoiding duplicate services like maybe expensive imaging, you know if the patient said they had an MRI maybe track that MRI down as opposed to ordering another one, encouraging your patients to just see a primary care physician regularly. So they're getting regular health care and not letting things get out of control. And then another thing you can do to really help yourself is to make sure you are coding comorbidities. So those are other problems that your patient has that you're probably not reading per se so you're not reading their diabetes, but maybe it's complicated, that you're the king. Maybe it has complicated your treatment of why they are seeing you. And so if that comes into decision making in your plan or care for the patient. If you code those out on your claims, then that patient, all of a sudden becomes a more complex patient in the eyes of Medicare, and they will allow more dollars to be spent on those episodes. So keep that in mind. And that's another thing you can do to positively impact your cost score. Now, the good news is that CMS changed the way the cost scores are being scored. And that is actually starting with 2024. And so what they I'm expecting or what they're telling us to expect is that we should probably have a little bit higher cost scores for 2024 going forward. And if you have more questions about cost at the end we can talk about it, but it is a really challenging category. So the next lesson learned is documentation, documentation, documentation. Now you don't have to have it in a paper format like I have here, but I wanted to bring to your attention that Medicare has a set of documents on the QPP website called the MIPS documentation criteria. And this criteria basically goes through what documentation you should have on file in case you're audited, and it covers all the categories, improvement activities, quality, and promoting interoperability. So you wouldn't have to maintain anything because they're calculating that. Other things you might want to maintain in addition to what they list, your certified EHR number, documentation of when you took your upgrade. If you're reporting to any public health registries, maybe a confirmation letter back from that registry that you successfully reported for the year. If your state registry provides exclusion letters, you can maintain that. But you want to make sure you have maintain that data, and that you have a backup of it. Because if you're audited and you can't produce something, that can really come back to haunt you. So that's my next question. Has anybody ever gone through an audit and not had some of the documentation they requested? So if you want to report that and chat and just kind of let your fellow attendees know what that is so that they can learn from your lesson there. And then the last lesson I wanted to talk about is know the impact of MIPS on your practice. And it doesn't have to be a super complicated calculation. You can take your Medicare allowables for the previous year and times it by 9% and say, if we don't do anything with MIPS, if we don't even consider reporting, this is the penalty we would take. And then go from there. So you know how it affects you. Also, you know, think about, well, if I do do MIPS, is there some benefit to that? Well, if you're selecting improvement activities that help your practice, maybe that's, you know, a positive to look at for reporting MIPS. Or maybe all those quality measures you're reporting also impact your quality to be able to participate in maybe like a commercial contract for, you know, some type of bundle. So those are just things to think about is, one, how it impacts you, but then what are some of the benefits of reporting? And so that's kind of the end of my presentation here. And I would like to now turn to the chat or if anybody would like to raise their hand and ask any questions or share your experiences or things that, you know, you've learned from reporting all these years. Thanks, Debbie. A while back, you asked about strategies. And so Emily from Concord Orthopedics in Concord, New Hampshire, said that they pull weekly reports to see where they're lacking and try to focus on those areas really closely. So it's good to see that frequency of reporting happening or review happening. Right, definitely. That's great. Stephen and I here to see if anybody else has comments or questions. We definitely have some time to cover anything or if there's anything that you are curious on related to MIPS that maybe Debbie didn't cover because it wasn't a lesson that she put in her presentation, feel free to ask about those. It doesn't just have to be about the content that's in here. Yeah. Yeah, I mean, I could have done a three week course on MIPS, you know, trying to squeeze it into just a short presentation. That's a challenge. Absolutely. Now, there is going to be some, some more requirements coming soon with MIPS, right? For some reason I was thinking that it was going to be, you know, coming into play in the next year or two, though, either the structure or the requirements related to it. Is there anything changing or something in the future that we need to be keeping an eye on? Well, there's definitely going to be there, there was a new version that we have to be on for this year, but I don't think that change to the software was anything that was going to be of a major impact to orthopedic practices, but that doesn't mean you don't have to be on the most, most recent certified version you still do. And then there's a new version of software, which I'm still unclear what, what they're upgrading and what the requirements are that are going to impact us so we will have to take another software update, and that'll have to be in place by July 3 of next year to report 180 days for promoting interoperability. They are still, you know, adding new MVPs, MIPS value pathways as an option. I don't think they've set an exact date that when they're going to eliminate regular MIPS, I think they're still kind of short on the selection of MVPs to cover all the different specialties out there. And so I think that's still kind of up in the air. Yeah, I actually have a question this hasn't come in the chat but just my curiosity. When you're thinking about onboarding a new system like an EMR or really anything, MIPS related, is there any kind of like notes that either you or anybody else in Signature that they try to, you know, make sure is a requirement for any new vendors you bring on board? Well, I mean, one, if the vendor is, you know, if the vendor is certified, you know what I mean, if, and you can always check to see if they have a pretty good reputation by going to that. There's a website, abbreviation is CHPL, C-H-P-L, and it tells you what the current certified version is. But one thing I would really want to know is what measures are they certified to report? And are they certified to report an MVP? If you've been doing an MVP and they're not certified to report an MVP, you know, it could really cause disruption of your workflow. So just, you know, be aware of that when you're selecting your new EMR. Absolutely. And actually related to EMR as well. Delenia said, we're changing EMR this year. We've heard that we'd be exempt from reporting. Do you know if that's correct? Just because they're changing an EMR? I don't think that guarantees it. You might be able to, yeah, I would say check. Check on the QPP website and read. Maybe you would be excluded from promoting interoperability, but I don't know if that would really exclude you from reporting all of MIPS because it's not going to stop you from doing improvement activities. And you could do quality measures through a QCDR. So I don't know if they would give a blanket exclusion from reporting. Yeah. And it looks like somebody in the chat said that they're changing EMR and were told they were not exempt. So if there's any question around it, or if you like saw that on a website or something, I would maybe include like the link to that and send something to the help desk with CMS. Because if they see that somebody is saying you're exempt, whether it's a, you know, maybe it's the vendor, like there needs to be a clarification there for everybody, it sounds like. Yeah, I would definitely want to get something in writing from the QPP help desk saying so. Yeah, absolutely. All right. Does anyone else have other questions or comments or tips they want to share? We'll give it another moment. And while we do that, I do want to provide a reminder that this recording is going to be available in the AOE Learning Center. We'll have the slide deck available as well. And we'll also have a handout that kind of summarizes. And in about a week or so, we'll also have a webinar summary. And so you'll be able to kind of catch the highlights of that. And you can absolutely print those out, share that with your team. That helps report on any of those handouts that are helpful. Maybe put them in a break area or other shared space or email it out to your team. And, you know, thank you so much, Debbie, for providing such great information here. I learned a lot today. I'm sure that the other folks on the call did as well. It's a really important topic. And there's a lot of benefit to it. But there's a lot of specifics you need to be covering and doing it right in order to get that benefit. So very helpful, good information here. And if you have follow-up questions for Debbie, then let us know. We can get them over to her and make sure that you have any follow-up questions answered. And, you know, we're thankful for all of you for attending. The next webinar we have is coming up on March 17. So if you're part of a hospital network, we're doing a webinar on how to maximize your experience at conference. And so definitely join us for that one. We'll also have one that week on benchmarking, maximizing your experience in the benchmarking survey. So keep an eye out for lots of additional webinars coming up. And we will see you all the next time around. Thanks again, Debbie. Really appreciate all of your help and support. Okay. Thanks, everybody. Bye. Bye. Oh, wait. Actually, it looks like we have just one more. Does anyone use living will or power of attorney for MIPS? I'm asking where the living will is. The advanced care plan measure? I'm not sure if you can clarify that, Kristen. That would be helpful. Yeah, and I'm on Collaborate, you know, so if anybody has a question, you know, you can post on Collaborate and I will get to it too. Yeah, absolutely. We do that as a quality measure. We ask about advanced directives. Right. And she said yes. Document with registration. Yeah. Great. Okay. Thank you. All right. Thanks, everybody. Really appreciate everyone and looking forward to seeing you all next time around.

MIPS

quality reporting

QPP team

interoperability

quality measures

CMS benchmarks

cost measures

financial impact