Navigating the Merit-Based Incentive Payment System (MIPS) has always been challenging, but 2024 is set to push even the most experienced participants to their limits. With its eighth year comes a new wave of stringent requirements, turning an already complex process into uncharted territory for MIPS veterans and novices alike. However, these new frontiers don’t have to be intimidating.
We're here to help you navigate MIPS 2024 and let you know where the dragons are so you can avoid them. In this blog, we focus on the Promoting Interoperability (PI) category.
The PI category has undergone the most significant overhaul. This category has always been crucial, but the changes for 2024 make it more so. Let us explore these changes and what they mean for your organization.
Clinicians Required to Report PI in 2024
Starting in 2024, the PI category reporting is mandatory for the following (previously exempt) clinician types. It is no longer automatically reweighted for them, and they must report the data. These clinicians are:
Physical therapists
Occupational therapists
Qualified speech-language pathologists
Qualified audiologists
Clinical psychologists
Registered dieticians or nutrition professionals
PI Reporting Period and Score
Reporting Period: All providers required to report the PI category of MIPS in 2024 must comply with a reporting period of at least 180 continuous days (up from 90 days in prior years). As of today, we have less than 180 days left in 2024.
PI Score: The PI category score is based on 100 points and carries a weighted score of 25 out of the total MIPS composite score.
HERE BE DRAGONS
Ensure you can get the data from your EHR for reporting, and that your EHR can provide a certification ID.
To achieve a minimum MIPS score of 75 points to avoid a penalty, you would need to report for the PI category unless you qualify for automatic reweighting or can claim an exception.
PI Measures and Updates
E-Prescribing
Providers are required to electronically prescribe medications to enhance accuracy and reduce errors. This measure now includes the Prescription Drug Monitoring Program (PDMP) requirement. Providers must check the PDMP database before prescribing controlled substances, which helps to prevent over-prescribing and supports efforts to combat the opioid crisis.
The e-Prescribing portion has a 10-point maximum based on a performance rate. There is an e-Rx exclusion if you prescribe fewer than 100 prescriptions in the reporting period. If excluded the points reweight to the Health Information measure.
The PDMP portion is worth 10 points when you attest to checking at least one patient prior to prescribing a controlled substance. Alternatively, you can achieve 10 points if you attest to the PDMP exclusion if you do not prescribe controlled substances.
HERE BE DRAGONS
Is your EHR capturing the e-Precribing rate correctly? Confirm that your e-Prescribing performance rate is tracking near 100%. This measure captures the number of prescriptions written electronically (numerator) out of the total prescriptions written (denominator) to the pharmacy. Since most prescriptions are sent electronically, close to a 100% performance rate can be expected.
Have you completed at least one PDMP prescription check? Make sure that before writing a prescription for a controlled substance, you conduct at least one PDMP check to determine if the patient has a current prescription from another provider. This is an attestation that a PDMP was conducted during the PI reporting period.
Health Information Exchange
Providers must electronically share patient health information using certified electronic health record technology (CEHRT) with other healthcare entities, improving care coordination and ensuring seamless patient care. A provider can earn 30 points for this measure by:
Being fully engaged within the Trusted Exchange Framework and Common Agreement (TEFCA) bi-directional patient data exchange program – 30 points; or
Being fully engaged within a Health Information Exchange (HIE) a bi-directional patient data exchange program – 30 points; or
Sending a patient encounter document (C-CDA), TO another provider - 15 points maximum; and
Receiving a patient encounter document (C-CDA), FROM another provider - 15 points maximum
NOTE- A provider can claim exclusion from this measure if sending or receiving fewer than 100 C-CDAs in a reporting period. If excluded, the 30 points will reweight the Provider-to-Patient Exchange measure.
HERE BE DRAGONS
Determine how you are participating in the electronic exchange of patient information with other providers: C-CDA, HIE, or TEFCA (new in 2024). EHRs most commonly facilitate sending and receiving C-CDAs for encounter summaries of recent visits.
Check the Health Information Exchange performance rates on your EHR’s MIPS dashboard. This will allow you to see if you qualify for reporting or can claim an exclusion.
Provider-to-Patient Exchange
Providers must give patients timely electronic access to their health information. The access is provided through a Patient Portal and or an FHIR-based API allowing a third-party app of the patient’s choice. This measure has no exclusions, and failure to report on it will result in a zero score for the entire PI category.
This measure has a 25-point maximum unless any of the other excluded measure points have been added to this measure due to reweighting.
HERE BE DRAGONS
As this measure does not have an exclusion, if you do not have a performance rate for this measure, your PI category score will be ZERO even if you report on every other measure and earn full scores.
Make sure that you have an email address for each patient on file (the patient’s or their authorized representative’s email address). Your EHR will enable you to send invitations to patients to access their data via a portal and your practice’s FHIR API (required to prevent information blocking under the Cures Act) using this email.
Public Health and Clinical Data Exchange
Providers must report data to public health agencies and clinical registries, supporting public health initiatives and enhancing population health management. There are two required measures to report or exclude, and three optional measures within the Public Health measure. These are:
Immunization Registry Reporting - Bi-directional communication with immunization registries.
Electronic Case Reporting (ECR) - Automatically reporting patients with certain triggering conditions (e.g. COVID).
Optional Public Health Measures - Reporting any one of the optional Public Health measures earns 5 bonus points.
Clinical Registry - Active engagement to submit data to a clinical data registry (e.g., a cancer registry)
Syndromic Surveillance - Active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.
Public Health Registry - Active engagement with a public health agency to submit data to public health registries.
Providers can claim exclusion from the Public Health measures if they do not diagnose or treat the targeted conditions.
If excluded the 25 points will be reweighted to the Provider-to-Patient Exchange measure.
HERE BE DRAGONS
If you provide immunizations, you are most likely in a specialty that also treats patients with conditions that trigger electronic case reporting (ECR).
If you do, you will need to attest to both mandatory measures: Immunization Registry and ECR. If you don’t provide immunizations, you might be able to claim an exclusion for both these measures.
SRA and SAFER Guides
Providers must complete a Security Risk Analysis (SRA) and review the Safety Assurance Factors for EHR Resilience (SAFER) guides to earn a PI category score. There is no exclusion available for both of these measures.
“SRA, SAFER guides, and Provider-to-Patient Exchange are required measures with no exclusion. Failure to report on any of these measures will result in a zero score for the entire PI category”
SRA: This analysis identifies potential security risks in the EHR system. Providers must address these risks to protect patient data effectively.
SAFER Guides: These guides help assess and optimize the safety and usability of EHR systems.
Providers must ensure compliance with these critical measures to safeguard their overall MIPS final score.
HERE BE DRAGONS
The SRA, SAFER guides, and Provider-to-Patient Exchange are required measures with no exclusions. Failure to report on any of these measures will result in a zero score for the entire PI category. Providers must ensure compliance with these critical measures to safeguard their overall MIPS final score.
CMS offers a very robust self-paced SRA that will fully satisfy what is needed for MIPS, as well as providing great insight into how your practice is covering the protection of Electronic Health Information (EHI). Download the CMS’s SRA tool
Key Takeaways
To avoid a penalty for MIPS 2024, a minimum overall composite score of 75 is required.
The PI category has a total of 25 points out of the total 100 for MIPS. (Quality - 30, Improvement Activities – 15, and Cost – 30)
The PI category reporting period is a minimum of any continuous 180 days.
A MIPS-eligible provider must address each measure by attestation, a performance rate, or exclusion, if available.
A provider must obtain the PI data from their use of Certified Electronic Health Record Technology (CEHRT).
The MIPS-eligible provider must have a Patient Portal and an FHIR-based API available for patients to Access, Exchange, and Use their Electronic Health Information (EHI).
With the optional Clinical Registry, 105 points are available for the PI category; however, a provider can only score a maximum of 100 points.
MIPS-eligible providers in practices of 15 or fewer can choose to opt out of the PI category. If they do, the 25 points will be reweighted to other categories.
There are less than 180 days left in 2024. You must’ve begun data capture for the PI category on or before July 1st.
*Review MIPS in 10 Steps to gain a deeper understanding of PI category measures, exclusions, exceptions, scoring, and special considerations.
If you find yourself needing further clarification on navigating the Promoting Interoperability category for MIPS 2024, do not hesitate to seek guidance. Up to 9% of your 2026 Medicare Part-B revenue is at stake.
MyMipsScore has been a CMS MIPS Qualified Registry since 2018. We have worked with provider organizations of varying sizes, including multi-location and multi-specialty practices and hospitals. We have had the honor of serving clients from diverse specialties ranging from Behavioral Health to Podiatry (literally from head to toe). When it comes to MIPS reporting, we’ve handled all kinds of complexities - from data acquisition and analysis to seamless submission to CMS. No matter what your MIPS challenge is, we strive to address it in a holistic manner so you can optimize your MIPS score and maximize incentives.
Ready to conquer the unchartered territory of MIPS 2024?
Contact us today for expert guidance.