ACG Guidance: Practical Tips for Reporting MIPS Data

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    Whitfield L. Knapple, MD, FACG
    Chair, Legislative and Public Policy Council

    As ACG has previously reported, CMS has opened the “Quality Payment Program” website to submit your 2017 MIPS reporting data.  ACG members can click here to begin the process.  The 2017 submission period runs from January 2, 2018 to March 31, 2018.  Group practices who are using the CMS Web Interface have a different submission period: January 22, 2018 to March 16, 2018.

    Here are some practical tips for GI practices and ACG members:

    Your first step: Find out your status (you may not need to report data)

    Determine whether or not you have to worry about MACRA.  Click here and enter your 10-digit National Provider Identifier (NPI) number.  This will tell you whether you meet the thresholds in order to be required to participate in MACRA.  Who has to participate in MACRA for the 2017 reporting year?

    1. If you are a: physician, physician assistant, nurse practitioner, clinical nurse specialist, or CRNA; and
    2. If you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year.

    Your second step: If you meet the eligibility requirements and want to submit your data

    You need your Enterprise Identity Management (EIDM) account to log on.  This is the account that you or your practice managers used to access your practice’s quality and resource use report (QRUR), or if your practice previously participated in the physician quality reporting system (PQRS).

    Forgot your credentials? Go to the CMS Enterprise Portal to reset your user ID or password.

    Don’t have a user account yet? Visit the CMS Enterprise Portal to create one, or call 1-866-288-8292.

    From there, the website will send you a verification code to your cell phone or email on file.

    Once you are in the system, you will see your personalized MIPS “Dashboard” where you should find each tax identification number (TIN) associated with your National Provider Identifier (NPI) number.

    You will need to select whether you are reporting as a “group practice” or as an “individual.”

    You will be able to select which MIPS performance category you plan on submitting data for at this time: Quality, Advancing Care Information (aka the new Meaningful Use), or Improvement Activities.

    • You have the option of uploading a file of your reporting data (if you are downloading measures from an EHR, for example)
    • For each performance category, you will select the time period for which you will be reporting data (For example: 90 continuous days)
    • For requirements attestation (“yes” or “no” answers), you will have to answer these first before the system will allow you to answer the other attestation questions

    Please Read: Some Important Things to Note

    You will find that there is no “send” or “submit” button when inputting your data.  Once you enter the data, the website will automatically calculate these data and scores.  You can re-enter data at any point prior to the applicable March deadline.

    By attesting to these questions, numerators/denominators, etc. CMS assumes that you are answering these questions truthfully.  CMS also reserves the right to audit your data at a later point.  Thus, documentation and record retention is important.

    While this is real-time scoring, there is still data that CMS still needs to add to your dashboard.  For example, CMS has yet to add your data if you are reporting quality measures via Medicare claims, or participating in MIPS via a registry or quality clinical data registry (QCDR).   CMS says these data will be added to your dashboard later this year.

    CMS has also developed instructional videos to walk you through the process of logging into the system and entering data.

    Whitfield L. Knapple, MD, FACG

    Chair, ACG Legislative and Public Policy Council

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