2020 Hospital eCQM Reporting

IQR eCQM Requirements  For 2020 there’s good news:   CMS has reduced the number of eCQMs you can choose from.  In 2019, there were 16, now only 8. Participants must report on 4 CQMs from the list below: The reporting period continues to be one self-selected quarter of the 2020 calendar year. While you are only required to submit 4 eCQMs, your EHR must be certified for all 8 eCQMs listed above.   More good news!  The Quality Net site has been totally re-done.  Hands-on users report that the new site is much easier to use than the old. Joint Commission Here’s a quick overview of eCQM submission for the Joint Commision (TJC):   Hospitals are now required to submit via the Direct Data Submission (DDS) platform, which was optional last year. Report for a minimum of one self-selected calendar quarter of data for calendar year 2020 Submission deadline for 2020 data is 3/15/2021.  For the 2019 reporting year, the deadline is 3/16/2020. For 2020, TJC is keeping ePC-01 (Elective Delivery) in their eCQM portfolio although this measure has been sunset by CMS. More excitement:  TJC has a new eCQM not included in the IQR list. ePC-02 (Cesarean Birth) ePC-02 is a new measure not available under the CMS IQR program.  ePC-02 reports the rate of Cesarean Births among pregnant women who have never delivered a baby before and where the baby presents in a normal position.  So, getting a bit more technical:   Numerator =       Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth   Denominator =   Inpatient hospitalizations for nulliparous patients delivered of a live term singleton newborn >= 37 weeks' gestation      Any DHIT clients interested in reporting ePC-02 should let us know ASAP.

MIPS/QPP 2020

Now that 2020 is here, how about 20/20 vision to focus on an outstanding MIPS score?  If that’s your goal, we hope this blog will help!  In case you weren’t paying attention, this is the 3^rd year of the Quality Payment Program (QPP) which spawned the Merit-based Incentive Program (MIPS) and Advanced Alternative PaymentModels (APMs).  The MIPS 2020 Final Rule was published November 1^st but maybe you missed reading due to its 996 page length, the busy holiday season, etc.  So here’s our synopsis – for the sake of brevity, we’ll skip the eligibility and APM criteria and focus on requirements for those who opt in (voluntarily or kicking and screaming!) for MIPS/QPP.

Overall Scoring and Financial Incentives

• Quality: 45%, Cost 15%, Promoting Interoperability (PI) 25%, Improvement Activities (IA) 15% -- these are all the same as last year and the weighting is unchanged, although CMS is mandated to make all categories 30% by 2022.
• The Performance Threshold increased from 30 points to 45 points. For clinicians, this means you’ll have to score at least 45 points to avoid a penalty. Conversely, the exceptional performance threshold increased from 70 to 85 points.
• Greater financial penalties and rewards – non-participants get dinged 9%. Theoretically, bonuses could also be up to 9% but probably won’t be that high due to budget neutrality requirements.
• Reminder that starting with 2018 (Year 2) data, MIPS scores will be publicly reported on the Physician Compare website.

Quality Performance Category

• Medicare Part B Claims measures: 70% sample of Medicare Part B patients (up from 60%) for the performance period
• QCDR measures, MIPS CQMs, and eCQMs: 70% sample of clinician's or group's patients (up from 60%) across all payers – no “cherry picking” is allowed.
• Driven by the Meaningful Measures initiative, CMS removed 42 measures (quality ID #’s): 046, 51, 68, 91, 109, 131, 160, 165, 166, 179, 192, 223, 255, 262, 271, 325, 328, 329, 330, 343, 345, 346, 347, 352, 353, 361, 362, 371, 372, 388, 403, 407, 411, 417, 428, 442, 446, 449, 454, 456, 467 and 474. Of these, 4 were eCQMs: 160, 192, 371 and 372.
• On page 63214 of the Federal Register Final Rule, there is a table of recommended CQMs by medical specialty. I don’t normally endorse reading the Federal Register but this is a valuable resource. The following specialty areas were added for 2020:

o   Audiology

o   Clinical Social Work

o   Chiropractic Medicine

o   Endocrinology

o   Nutrition/Dietician

o   Pulmonology

o   Speech Language Pathology

Improvement Activities Performance Category

•          There are 2 new IAs, 7 modified IAs and 15 that were removed.

• Page 63514 of the Federal Register has a table of all 2020 IAs.
• For groups, the threshold re. number of clinicians for an IA has increased from just 1 to at least 50% of the group for any continuous 90-day period.

Promoting Interoperability Performance Category

• The optional Query of PDMP measure will require a Yes/No response instead of a numerator/denominator.
• The optional Query of PDMP measure has been removed.

Cost Performance Category

• There are 10 new episode-based measures:

Measure	Episode Measure Type
Acute Kidney Injury Requiring New Inpatient Dialysis	Procedural
Elective Primary Hip Arthroplasty	Procedural
Femoral or Inguinal Hernia Repair	Procedural
Hemodialysis Access Creation	Procedural
Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation	Acute inpatient medical condition
Lower Gastrointestinal Hemorrhage (applies to groups only)	Acute inpatient medical condition
Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels	Procedural
Lumpectomy Partial Mastectomy, Simple Mastectomy	Procedural
Non-Emergent Coronary Artery Bypass Graft (CABG)	Procedural
Renal or Ureteral Stone Surgical Treatment	Procedural

To Summarize:  CMS has once again raised the bar and the financial stakes, so we recommend starting your MIPS/QPP planning ASAP and monitoring scores regularly throughout the reporting year.  Our Dynamic Registry platform has great tools for this and is available with or without contracting for our services as a QPP Qualified Registry.