Index

• Sections
  • Minimum reporting 2019 using Quality category and Improvement Activity category
  • Minimum MIPS requirement 2019 to avoid penalty – 30 points
  • Quality Measures 2019 – 45 % of total MIPS score
  • Measures Certified by ICANotes
  • High Priority Measures in Order of Highest to Lowest Scoring
  • Other Measures in Order of Highest to Lowest scoring
  • How to Report on Quality Measures in ICANotes
  • Improvement Activities - 15% of Total MIPS score
  • Provide 24/7 Access

Minimum reporting 2019 using Quality category and Improvement Activity category

Minimum MIPS requirement 2019 to avoid penalty – 30 points

Quality Measures 2019 – 45 % of total MIPS score

Measures Certified by ICANotes

• One of the measures must be High Priority.
• Report on as many other measures as possible to see which you can get scores for.
• You must have a minimum of 20 patients in the denominator for any measure to get as many points as possible.
• Data completeness for a quality measure = 60% of all patients seen can be reported on for a measure submitted.
• Small practices (15 clinicians or less) – Earn 3 points for a measure if data completeness not met but some data has been reported. Earn a minimum of 18 points with reporting some data on 6 measures, 1 of which is a high priority.
• Small practices earn up to 6 points added to quality category provided they submit data on at least one quality measure.

High Priority Measures in Order of Highest to Lowest Scoring

• Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS 177)
• Closing the Referral Loop: Receipt of Specialist Report (CMS 50)
• Use of High-Risk Medications in the Elderly (CMS 156)
• Documentation of Current Medications in the Medical Record (CMS 68)

Other Measures in Order of Highest to Lowest scoring

• Depression Utilization of the PHQ-9 Tool (CMS 160)
• Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (CMS 22)
• Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS 2)
• Preventive Care and Screening: Body Mass Index (BMI)Screening and Follow-Up Plan (CMS 69)
• Dementia: Cognitive Assessment (CMS 149)
• Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS 161)
• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (CMS 138)

How to Report on Quality Measures in ICANotes

The CQM/PopHealth course shows how to report on the individual measures. 

Improvement Activities - 15% of Total MIPS score

Relevant to behavioral health clinicians include:

• Provide 24/7 access
• Depression Screening (using an age appropriate screening tool)
• Electronic Health Record Enhancements for Behavioral Health data capture
• Tobacco Use
• Unhealthy alcohol use (using an appropriate screening tool)
• Engagement of patients
• Family and caregivers in developing a plan of care

Go to qpp.cms.gov to see full list of Improvement Activities.

Provide 24/7 Access

The Provide 24/7 Access is a high-weighted activity and can be demonstrated easily by the clinician going in after practice hours. A small practice - 15 clinicians or less - would then earn the entire 15 points for Improvement Activities.

Here’s how:

Select Reports/Audit Log and then take a screenshot of the Audit Log at that time. This then shows the clinician has accessed the program after hours.

Take screenshot of the audit log at the beginning of the 90 days, once in the middle and then at the end. This shows that the EHR can be accessed at any time.

Keep any screenshots for 6 years in a “Book of Evidence” in case of a future audit.

Improvement Activities is an attestation only category.

<span style="font-family: arial, helvetica, san