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MEDENT - Version 23.5  11/29/2023

See Also:

MIPS Reporting - Prior Years

Data Validation and Auditing

2022 Quality Dr Setup

2022 Specialty Groups

 

The Quality category is only one part of the reporting needed for the Merit-Based Incentive Payment System (MIPS).

This report is designed for the EHR reporting of the Quality category of MIPS. For more information on this program and its components see https://qpp.cms.gov/mips/quality-measures.

This 2022 Quality Quick Start Guide outlines the reporting options and quality measure scoring for 2022.

The Quality performance category is a 12-month performance period (January 1 – December 31, 2022).

MEDENT Support: All correspondence relating to eCQMs must include Judi D.

 

2022 Quality Checklist for EHR Reporting:

Review the QPP website: https://qpp.cms.gov/mips/quality-requirements?py=2022.

Complete the Reporting Options Setup.

Review the measures available and documentation areas for actions included in measure.

Select 6 measures, including at least 1 outcome measure. If an outcome measure is not applicable, select another high priority measure.

Review that all measures are applicable and the clinician will see patients that fit into the denominator for every measure selected.

Periodically run the Quality report using date range 1/1/22-12/31/22 for measures selected to be sure data is being captured appropriately.

 

Note: An eligible clinician can decide to change measures at any point in time. The report is only generating the data as a reference to track progress. The reporting will be done AFTER the performance period, at which point the report will need to be exported.

 

For questions regarding applicability please view the details on measure(s) in question.

 

Settings / [F2]: Add, load, update, and delete settings for which Quality measures to run for selected providers. The Setting will store the Report Type, the selected provider(s) (or TIN), the selected measures, and the date range. To update settings that have already been saved, make the appropriate changes on the report options screen, click Settings, click Update, and answer Yes to overwrite the stored setting. This allows multi-specialty offices to select the measures that are appropriate for the providers in a specific specialty, e.g., cardio, ortho, etc..

 

Report Options

Beginning Date / Ending: Reporting period dates. This should always be 1/1/22 - 12/31/22. Note: A full year of reporting is required to participate.

The default date range is 01/01/22-12/31/22.

If the defaulted date range is changed to anything less than the full calendar year, the following message will be displayed:

You have selected a date range that is less than a full calendar year.

Quality Measures should only be run for the full year to give the correct results.

 

Version During Reporting Period: Select MEDENT version(s) during reporting period. The default is V23.5.

MEDENT V23.5: The practice used version 23.5 for the entire reporting period.

MEDENT V23.0 & V23.5:The practice updated to version 23.5 during the reporting period.

 

Report Type: Select the method of submission your providers are reporting.

Individual EHR Reporting Option (2022 Reporting): This option is for eligible clinicians reporting as individuals. If an eligible clinician is set up to bill as TIN by Location, separate reports will be created. Each report will only include patients whose 2020 e-superbills include a Location that corresponds to that TIN. Upon export, a QRDA III file is generated with totals. This file includes percentages for each measure.

GPRO EHR Reporting Option (2022 Reporting): If you choose to participate in MIPS as a group, you will need to collect and submit the available data from all of the clinicians in your group as appropriate to the quality measures you select. This includes the data of clinicians that are not eligible for MIPS or a MIPS payment adjustment. Upon export, a QRDA III file is generated with totals. This file includes percentages for each measure of the entire group. Note: If there was more than 1 active TIN during a reporting period, the report should be run for each TIN individually.

 

Provider(s): For Individual Reporting Only. Providers marked as MIPS-Eligible, but Excluded or Non-MIPS Clinician will not be included. These flags are set in Reporting Options Setup.

For eligible clinician(s) billed under more than one TIN in the performance year, the report will be broken out by the dates associated with the TIN in the Location Setup. The eligible visits will then be reported under the appropriate TIN.

If a doctor has been deactivated and/or the user associated with the doctor has been deactivated, the user can click MEDENTmenuoptions and select Show Deactivated to include these providers in the report.

 

Tax ID Number(s): Available when Report Type is set to Group. This will run for All TINs (in most cases there is only 1), or the user can select a specific TIN to run the report. Note: Providers marked as MIPS-Eligible, but Excluded WILL be included in the group calculation. Providers marked as Non-MIPS Clinician will be excluded from the group calculation. These flags are set in Reporting Options Setup.

If the practice is set to report as a Group in the Reporting Options Setup, the report can still be run individually by changing the Report Type to Individual.

If there is more than 1 TIN, the report will be broken out by the dates associated with the TIN in the Location Setup. The eligible visits will then be reported under the appropriate TIN.

Data for doctors who have been deactivated will be included in reports, as their data is pertinent to the reporting criteria of the performance of the group. Note: The doctor will not be listed in the TIN selection screen.

 

Measures: Select measures to report, based on services provided. Select six measures including one outcome measure. If an outcome measure is not available that is applicable to your specialty or practice, choose another [high priority] measure. Note: Choosing to report on only one measure may only avoid a downward payment adjustment.

Overall documentation requirements:

Encounters: To meet this requirement, an e-superbill should exist for each visit (including one of the encounter codes required for the measure).

The e-superbill must have a status of Patient Seen or Closed and any additional e-superbill statuses that were setup in E-Superbill Statuses.

If there is no e-superbill for a visit, the measure programming will subsequently search for an encounter CPT or HCPCS code in the CPT/HCPCS chart area.

Post-operative visits (CPT 99024) will count as Encounters in the following measures: 50, 74, 75, 117, 122, 124, 125, 127, 128, 130, 131, 134, 135, 136, 138, 139, 142, 143, 144, 145, 147, 149, 153, 154, 155, 156, 157, 161, 165, 177.

If more than one encounter is required, at least one e-superbill must meet one of the following conditions:

The Eligible Professional is the PDr OR

The Eligible Professional is the SDr for a provider not indicated as a Doctor, NP or PA in the Doctor Setup OR

The Eligible Professional is the SDr for a provider indicated as an NP or PA in the Doctor Setup AND the Include NP/PA flag is checked in Preferences.

If the PDr is set to Yes for Nurse's/Non-EP's Schedule in the Doctor Setup the patient will be excluded from reporting. Note: It is up to the office to determine if it is appropriate for this "doctor" to be excluded from measure reporting.

135, 138, 144, and 145 require >= 2 encounters during the measurement period with the SAME eligible professional.

 

Patient Gender: The Quality Measures determine Patient Gender using the Sex at Birth field on the Patient Information screen.

If Sex at Birth is not answered, the Quality Measure programming will default to the Sex field on the Patient Information screen.

If Sex at Birth is answered with "Unknown", the patient will not be included in any gender-dependent measures (124, 125, and 153).

Dx Codes: The measures will read SNOMED codes in the Problem List and ICD-10 codes in Dx History for the diagnosis  documentation requirements.

Active Dx: If the measure requires an Active Dx, it must be documented in one of the following areas:

A SNOMED diagnosis code must appear in the Problem List and have an Active status. (Resolved status will not be recognized for this). The date of the SNOMED code does not have to be during the measurement period as long as the Problem List status is set to "Active".

OR

An ICD-10 diagnosis code must appear in the Dx History and be dated during the measurement period to ensure it is a recent diagnosis.

Resolved Dx: If the measure requires a Resolved Dx, it must be documented with a SNOMED diagnosis code in the Problem List, the status must be set to Resolved, and the Resolved date must be entered. (ICD-10 codes in Dx History will not be searched for this.)

Document Components in Progress Notes or Nurse Notes: Several measures include documentation requirements for Document Components in Progress Notes or Nurse Notes.

The Progress Note/Nurse Note master document codes searched for:

Document Components are: OBGNU-NURS, UROLNU-NOT, NOB, NOF, NFP, NFF, NU1, NU2, and any document code beginning with NOTE____.

Any document code with LOINC 11506-3 attached.

Any document code assigned to the NOTES chart button.

For measures CMS 2, 138 and 149, the following Occupational Therapy progress notes are also searched: OT-.REEVAL and OT-.DSCHRG.

For measure CMS 69, the following Physical Therapy and Occupational Therapy progress notes are also searched: PT-.REEVAL, PT-.DSCHRG, OT-.REEVAL, and OT-.DSCHRG.

Labs / Diagnostic Imaging / Orders: Measures with documentation from Labs, Diagnostic Imaging, and Orders will require appropriate codes, status dates, and when necessary, the Result.

Labs: Lab orders must have Lab Tests associated with appropriate LOINC codes. Labs must also have an Acquired Date and Result documented.

Diagnostic Imaging: DI orders must be associated with appropriate LOINC codes and do not require documentation of a Result. An Acquired Date is required to satisfy Numerator criteria. CMS 153: DI Orders only require an Ordered Date to satisfy the Denominator Exclusion.

General Orders: Orders must be associated with appropriate SNOMED or CPT/HCPCS codes. Orders must have the Ordered Date and the Received Complete (RcvdCp) Date.

 

 

 

Report Output:

The report output will display on the screen once it has finished if run for a single provider. If the report was run for multiple providers at once, the individual reports for each provider will be found in Previously Run Reports.

(*) indicates that this is an Outcome Measure.

When GPRO reports are either printed or viewed in browser, the full list of doctor numbers and names are listed at the top. The doctor numbers can also be viewed in a tool tip when hovering over "Doctors" at the top of the report.

 

If at least one of the measures in the report doesn't have enough patients in the denominator to be scored based on your performance, a message will appear at the bottom of the report output: Note: Measures with a red denominator do not meet minimum case requirements to be scored for performance (Den-Excl-Excp >= 20). If reported, the best possible score would result in 3 points per measure in performance year 2022.

CMS could still give the provider/practice credit for reporting, but would only result in, at most, 3 points in performance year 2022. In order to be counted for performance, a measure needs to contain at least 20 occurrences.

 

 

2022 Quality EHR Measure Specifications

2022 EHR Benchmarks