MIPS and MACRA – Frequently Asked Questions

MIPS and MACRA – Frequently Asked Questions

Click here to download FAQs from Feb. 15, 2017 webinar


Click here to download FAQs from March 9, 2017 webinar


MIPS and MACRA Frequently Asked Questions

Do we have to do the quality measures that we have previously done from the patient chart under Actions?

  • No. The quality measures that you need to complete are listed under the new MIPS Quality Measures Editor in the patient’s Encounter.

Is it recommended that I complete the Quality Measure via claims or registry?

  • Since claims require you to submit your quality measures at the time of claim submission, I would recommend registry, as it allows you to go back and gather the data needed retroactively.

What about the medication and pain measures? Do they need to be done at each visit?

  • Yes, these measures should be completed “at each denominator eligible visit.” As TRAKnet is MACRA Intelligent, it will tell you which visits are denominator eligible in the MIPS editor window.

Can referral be incoming?

  • For the additional measure under Advancing Care Information, regarding Health Information Exchange, this measure is for patients who were transitioned out to another heath care clinician – in other words, outgoing referrals.

What is the CMS website for research?

What percentage of Medicare Part B patients are needed for claims-based reporting?

  • The threshold to meet is 50% of all unique patients for a 90 day period for both claims-based (Medicare Part B) and registry-based (all carriers) reporting.

Do you just click the button on the Quality MIPS Editor, or do you then have to go back into your note and make separate documentation?

  • All patients must have documentation matching the measures that are being reported on. The MIPS template will not populate the editor or the invoice. The Quality MIPS editor will not populate the note. If you choose registry reporting, the Quality MIPS editor will gather the data for registry reporting and store it in the database. If you choose claims reporting, the MIPS Quality MIPS editor will populate the invoice.

Have you gotten more clarification on the A1c measure? Do we need to get the hard copy/scanned multimedia in the system in order to be able to document #001 Quality Measure?

  • This requirement has not changed. Users must have the Hb a1c documented on a lab report – it cannot be self-reported by the patient.

With the CCD-A I have noticed Medicare patients that did not have an email and it turned red. I have also noticed it not turn red with Medicare pts that did supply an email – why inconsistent?

  • This is based upon your unique patients and their current encounter. It is not based on whether you have an email or a specific insurance.

Where are the new templates located?

  • The new MIPS templates are located under Templates > MIPS.

When reporting via Registry, is there a specific registry best used with TRAKnet?

  • TRAKnet is integrated with the MedXpress Registry. I have worked with MedXpress and been very happy.

Can we check the measures under the invoice and put the information into the encounter without using the MIPS template?

  • In order to have TRAKnet track the data, users need to click on the Quality MIPS editor. You do not need to use the templates for documentation.

Why would we choose report by claims if some diabetic measures requires through registry only?

  • Users only need to choose 6 measures so none of the diabetic measures need to be used of you don’t wish to use them. If a user wishes to report on all possible diabetic measures, then the user must choose registry reporting.

If we choose to go longer than 90 days is that possible. We have a limited # of diabetic patients and in order to get them in we would need longer than 90 days.  Is that okay?

  • The quantity of data reported is not as important as the quality of data reported. Reporting longer than 90 days is not needed as long as the quality of data is good.

I am a full member of an ACO. They have said they will be reporting the Quality on my behalf. Is anyone aware of what and how my responsibility on my end would be?

  • Most DPM’s will not qualify to report via APM’s. I would check with them to ensure they are reporting on your behalf. I would recommend reporting on your own.

For claims submission for HbA1c do we submit codes only when elevated >9? Do we need the lab results from the MD?

  • All results should be documented, no matter the result. Yes, this information must come from lab results and not self-reported by the patient.

Does submitting the CCD-A suffice, or does the patient actually have to respond?

  • To meet the base measure, sending the CCD-A and giving the patient the ability to set up their portal is sufficient.

Early in 2017 we didn’t have the registry set up yet, so we were entering the codes in the claims. We are going to use the registry going forward. Will it be a problem with the claims already sent?

  • You can change to registry reporting for your 90 day reporting period.

For quality measures, how many patients does this need to be reported on?

  • Most measures need to be reported on in 20 patients.

If your note is complete and then you get to the end and report quality measures, how do you go back into your note and change or document what you now know needs to be added?

  • You must add an addendum to your encounter once it has been signed.

Do you have to have a charge in the invoice before MIPS will populate?

  • Whether claims or registry reporting, quality measures utilize diagnoses codes and CPT codes on the encounter.

What information is needed for documentation? Does documentation need to be in the encounter?

  • Information needs to be in the patient’s medical record, whether in the encounter or the chart.

Are new doctors required to report in MIPS?

  • Newly enrolled physicians in Medicare do not need to report in MIPS, but you can submit if you wish.

Can we pick our own measures that we feel fit our office this best?

  • TRAKnet has supplied you with 11 possible measures. You need to report on 6 measures.

Can you go back and amend closed notes since 1/1/2017 or can you only go forward?

  • If you choose to report via registry, you can go back and document the measures via the editor. Remember that you must have documentation to support the measures you have chosen.

The new report for e-prescribing ACI says “No”. Why is that? We have been e-prescribing all the time.

  • The reason it states no on the report is that this measure is required for your base measure reporting but this measure does not have any performance scoring. We will be updating the verbiage to eliminate confusion, however.

Do I have to subscribe for a portal? Can the CCD-A be faxed to the patient?

  • No. Utilizing the “Send to Portal” button under Actions in the CCD-A screen will utilize Microsoft HealthVault for sending the CCD-A information to the patient. The CCD-A can’t be faxed to the patient.

Do we have to report Quality Measures on all carriers if we use registry?

  • If you report for quality measures via registry you must report on all carriers, including Medicare.

What if we have been reporting on more measures than required/eligible?

  • There is no issue with reporting more than 6 measures. CMS will choose your 6 best measures.

How does TRAKnet know if something is documented?

  • TRAKnet does not know if something is documented in the patient’s chart or encounter outside of the specific criteria for each measure, such as age, CPT codes, or diagnoses.

How do we satisfy the MIPS Cost – which replaces the value based modifier?

  • Cost is not a factor for MIPS reporting in 2017.

Is there a way to have the back office assistant enter the Quality Measures -MIPS/MACRA information prior to starting the encounter?

  • While the quality measures entered are tied to a specific encounter’s diagnoses and CPT codes, an assistant can open up the encounter and enter the quality measures before any diagnoses or CPT coding is entered. Once entered, TRAKnet will be able to “tie it all together” and alert the user as to which measures are actually required.

For Health Information Exchange it says to use CEHRT to create summary of care AND transmit electronically. Faxing the summary of care outside the TRAKnet system isn’t technically using CEHRT. Is this acceptable?

  • For all software that is 2014 certified, faxing the CCD-A/referral document is acceptable.

For every patient invoice you must click on each performance measure and click the G code?

  • You only need to click on the measures that have a Yes in the denominator column.

If we enter measures (registry) when we don’t have to, i.e. with procedure codes, not E/M, and then the patient comes back for an E/M visit, do we have to do measures again, or will it still be there from before and link to the new visit.

  • Each visit is independent of each other. Since TRAKnet does not know your 90 day period, it takes each encounter independently.

So if I do 20 patients and use 6 measures at least on reporting, I am neutral?

  • It is even easier than that. If you report one quality measure on one patient, one time, you will remain neutral. Performing 6 measures on at least 20 patients will allow you to submit this data with all the other data and possibly receive an incentive.

When using the registry method, can you amend your record after it is signed?

  • If you report via registry, you can go back and gather the data after the visit. I would then recommend adding an addendum to the note regarding the addition of this information.

There are 11 measures listed. Are we required to satisfy all?

  • Providers need to document six measures. We have implemented 11 to allow the user flexibility in which six they complete.

Please tell me more about registry reporting.

  • If you submit your quality measures via a registry, all private insurance carriers are included, including Medicare. For the minimum 20 patients required for a measure, this does not have to be a majority of Medicare patients like it was last year for the diabetes measures group.

If you are doing registry do the reports change to pull ALL patients vs just Medicare?

  • TRAKnet is “MACRA Intelligent” and know what patients are required if you choose claims vs. registry.

Reconciling meds at every visit is a burden. Meds are in the chart but we have never reconciled them at each visit. Is this really necessary?

  • In order to utilize that Quality Measure, you must document that you have performed medication reconciliation at each visit.

What was the TRAKnet YouTube link?

For quality measures, do you complete this information on 20 patients to satisfy a measure?

  • Yes. You need to have a minimum of 20 patients in a measure for it to be used for reporting.

Does the documentation need to be for all patients or just for the Medicare patients or if they have a Medicare Advantage or HMO?

  • If you chose to report via claims, as opposed to registry, you only collect this information on Medicare Part B patients. Registry, however, is all patients.

When choosing how to report (we plan on registry) does the choice need to be made for each provider in the practice? If done on 1 computer in the office, does that translate to all other computers and the server?

  • When choosing between claims or registry, this only needs to be once for the practice and not on each computer.

Is there any advantage to claims made vs registry reporting of MIPS?

  • No. Reporting of MIPS data must be done at the time of claims submission. Using the registry option allows you to go back and retroactively enter the data.

What is an inverse measure?

  • An inverse measure is a measure where lower performance is actually better than higher performance and will earn you a better score. In regards to hb a1c, the lower your performance met, meaning the more times you choose the option for a patient with a lower hb a1c, the better you will be. The more you choose performance met, for your patients with an elevated hb a1c, the higher your performance and the lower your score will be.

What documentation is needed form the Primary for the a1c. Does it have to be a printed lab and scanned in patient’s chart? To utilize the A1C measure, do you need actual documentation from the lab or take the patient’s verbal statement?

  • In order to meet the requirement for this measure, you must have documentation of the a1c value, not just the word of the patient.

Would doing procedures on a non DM would not have any QM?

  • TRAKnet knows which CPT codes would qualify a patient to report a specific measure.

What if we collect the data on the first visit in the reporting period, but the doctor only codes 11721. Then the patient comes back for a E&M visit code on the next visit within the reporting period- do we collect the MIPS data all over again for the 2nd visit?

  • If the patient is treated for an E&M on the 2nd visit, you will need to collect the data for the quality measures that would qualify with the use of the E&M.

How often do we have to get the Hemoglobin A1c information?

  • You need to collect this information once per reporting period

In order to enter the a1c, do we add an addendum in order for it to be documented on encounter as well as have proof?

  • As long as you have the documentation of the hb a1c, it is up to you on how you choose to document it.

Not eligible means no mention of callous, ulcerative lesions or foot deformities?

  • A patient may not be considered eligible for a quality measure when they do not have the criteria for the measure. It is based on age, diagnosis and treatment codes.

Do we need documentation for flu or pneumonia vaccine?

  • Those measures can be self-reported by the patient

I have been putting the MIPS codes in the billing.  If I have the patient back in 2 weeks and I bill another OV, I notice that I have to re-enter all the MIPS again.  Is that right or is it just once in 3 months?

  • Regardless of claims or registry, you should utilize the editor for entry of the quality measures. If you choose claims, they will show up on the invoice. Certain measures need to be done on every visit, while others are only once per reporting period.

Are physicians in a group able to report differently or must they all report the same method?

  • All physicians in a group need to report via the same method.

Do we only need to document the 11 measures once per year if reporting for the whole year?

  • You only need to report on 6 measures, one of which needs to be an intermediate outcome measure (Meds and hb a1c are intermediate outcome measures)

If you get this information in Feb but you are reporting July – September, do you have to put it in again?

  • Collecting this data for an entire year will allow you to choose your best 90 day period. You need to have the data for the 90 day period you wish to report on.

We would appreciate a presentation on “via Claims” reporting only. Does the MIPS/MACRA tab export the measure codes onto the claim upon checking them there?

  • The only difference between Registry and Claims is that once the measures are checked off in the editor, they will appear on the invoice. That’s the only difference.

Is MIPS for just Medicare patients or for all of our patients?

  • If you are reporting via claims, you would only need to collect this data on your Medicare Part B patients. If you are collecting the information via a registry, you need to collect the data on all insurance companies.

Can the templates from the webinar be provided to us by TRAKnet?

  • A set of MIPS templates have been uploaded to your database. Edit them as you see fit.

I am ready to start now, but the registry is not ready to receive my data. What should I do?

  • As in all previous years, the information you collect will not be submitted until early the following year. Please collect your data now and be patient. The registry will be available to sign up soon.

Are the diabetic measures only reported via registry?

  • You can only submit those measures to the registry.

Do we need to get exact month for flu vaccine?

  • Recording of this measure will only be from Jan-Mar and Oct-Dec.

I do a lot of nursing home and assisted living facilities. Are they going to be included in the 90 days if I bill a 99307 or 99324?

  • For each measure, TRAKnet knows which CPT codes would qualify the patient for a specific measure.

Why in claims base can you not pick the specific 90 days?

  • While you can choose to place the measures on your claims for a specific 90 day period, if you do not perform well for that 90 day period, you would need to start all over again. The measures are on your invoice and can’t control which dates CMS should use.

Is MIPS is for all patients, whether they are in a Nursing home, or assisted living or hospital or house call? Can you uncheck the meaningful use tab to not count that patient? Is that allowed? Or is that frowned upon?

  • Depending on claims vs registry will determine your patient population on data collection. You should never uncheck your meaningful use tab for any face to face encounters with patients.

BMI outside normal limits, who is responsible for follow up plan – MD or podiatrist on next visit?

  • The measure states a plan needs to be documented. It does not state who should follow-up on an abnormal BMI.

Do we still have to use our Quality Measure Tab from the “Action” dropdown?

  • The Quality Measures for MIPS is now documented on the new tab in your Invoice screen.

On the invoice I saw a Quality Measure tab. We do not have that.

  • Once you go to Tools > Options and choose how you would like to report your data, either via claims or registry, the tab will appear

How will TRAKnet tell you it is not an eligible visit?

  • Depending on certain criteria, age, diagnosis, CPT code, TRAKnet will list in the Denominator column on the Quality Measure Editor a Yes or No whether the patient is eligible for a specific measure.

If your documentation at the nursing home is in a different EMR, how do you document all the info in the patient’s note?  Does it need to be done at the facility and also in TRAKnet?

  • The only way for TRAKnet to know if a patient is eligible or not for specific measures is to have the documentation in TRAKnet.


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