What are Common Errors Practices Make in MIPS Submission and How to Fix Them

This article discusses common errors in submitting data for the Merit-based Incentive Payment System (MIPS) and offers tips to avoid them, ensuring accurate reporting and potential penalties.

1. Misunderstanding Category Weights

It’s easy to get tripped up by the different weights assigned to each MIPS category. These weights aren’t fixed and can change based on your practice size and whether you’re reporting on Promoting Interoperability. If you don’t understand how these weights apply to you, your strategy for meeting the minimum scoring requirements might fall short, potentially leading to penalties.

For instance, Improvement Activities can significantly impact your overall score, especially for smaller practices. CMS also has the power to adjust or suppress benchmarks throughout the year, which could throw off your calculations if you’re aiming for the bare minimum. It’s a bit like trying to hit a moving target – you need to stay informed and adapt your approach as needed.

• Category weights can differ based on various criteria.
• CMS can change and suppress benchmarks throughout the year.
• A minimum scoring strategy could fail if CMS takes action on your MIPS measures.

Aiming higher for penalty avoidance is a safer, more conservative approach as it ensures compliance even if circumstances change during the performance period.

2. Ignoring Specialty Measure Sets

It’s easy to fall into the trap of just picking measures that seem familiar or easy to report. However, you might be missing out on some serious points by not paying attention to specialty measure sets. These sets are designed to include measures that are most relevant to specific fields of medicine. Ignoring them could mean you’re not showcasing your practice’s strengths in the most effective way.

Think of it this way:

• Specialty sets are tailored to your area of expertise.
• They often include measures where you’re likely to perform well.
• Using them demonstrates a focus on quality within your specialty.

Overlooking specialty measure sets is like leaving money on the table. You’re potentially missing out on easy wins and a higher MIPS score. Take the time to explore the measures specific to your field; it could make a significant difference.

Let’s say you’re a cardiologist. You could report on a general measure, or you could focus on measures specific to cardiology. The latter shows a deeper commitment to quality in your area. Plus, you’re probably already tracking a lot of this data anyway! It’s about making sure you get credit for the work you’re already doing. You can download the list and filter by specialty to see what’s available. Don’t let those easy points slip away!

3. Choosing Incorrect Submission Methods

The choice of submission method and collection type can significantly impact your MIPS score. Different methods offer varying measure collection types (eCQM, CQM, claims).  EHR submissions include a more robust selection of eCQMs and registry submissions can include both eCQMs AND CQMs, allowing for flexibility. Claims collection type submissions are more limited in measure options and only earn credit for claims with quality data codes, while EHR submissions earn credit for prescribed data fields mapped to nationally recognized standards. Registry submissions earn credit for discrete data, allowing clinicians to choose the most efficient workflow. 

Here’s why choosing the wrong method and collection type can hurt you:

• Limited Measure Availability: Not all submission methods support every measure. If your preferred measures aren’t available through your chosen method, you’re forced to pick less relevant ones.
• Data Capture Differences: Each method captures data differently. Claims submission relies on specific codes, EHR submission on mapped data fields, and registry submission on a broader range of data. This can affect how accurately you capture numerator (quality performance) data.
• Tracking Difficulties: Some methods, like claims submission, make it hard to track your progress. You might not realize you haven’t met the minimum reporting threshold until it’s too late because it’s tracked by CMS and reviewing it can be delayed.  

To avoid this, carefully consider the following:

1. Review Available Measures: Before committing to a submission method, check which measures it supports. Make sure it includes the ones most relevant to your practice and patient population.
2. Assess Data Capture Capabilities: Understand how each method captures data and whether it aligns with your existing workflows. Choose a method that minimizes disruption and maximizes accuracy.
3. Consider Tracking Options: Opt for a method that allows you to monitor your progress and identify any gaps in your reporting. This will give you time to make adjustments and improve your score.

4. Failing to Track Benchmark Changes

MIPS strategy is crucial for maximizing scores, as benchmarks do change year to year. CMS uses past clinician performance to set benchmarks, dividing performance into ten deciles representing 10% of providers in a previous year. Staying informed about these changes is key to aiming for a moving target.

Here’s what you need to keep in mind:

• Review benchmarks annually: Don’t assume last year’s data is still valid.
• Understand deciles: Know where your performance falls and what it takes to move up.
• Adjust your strategy: If benchmarks have changed significantly, re-evaluate your measure selection and performance goals.

Failing to track benchmark changes can lead to unpleasant surprises when you receive your MIPS score. Stay proactive, stay informed, and adjust your approach as needed to ensure you’re always aiming for the highest possible performance within the current MIPS landscape.

5. Overlooking Documentation Requirements

Documentation is crucial for MIPS data submission, as it provides solid proof and supports claims. When choosing MIPS quality measures, consider the documentation requirements, as some require multiple data points while others are simpler. The balance between reporting capabilities and documenting time should be considered when choosing measures.

Different submission methods also have different documentation needs, even for the same measure. For example:

• Claims submission: You’ll need to use specific codes like G-codes or CPT II codes. These codes make data entry faster by summing up complex events into a single input.
• EHR submission: You’re limited to the data fields your EHR has mapped to national standards. If your EHR doesn’t map user workflows well, it can create extra work for your team.
• Registry submission: This gives you the most flexibility because you can use any discrete data, even fields your EHR might not map. This lets your team pick the fastest, easiest workflow.

To ensure a smooth workflow, ensure your team can handle the documentation demands of the chosen measures. Choose measures that can be documented well, as not documenting them can result in lack of credit. It’s crucial to track all necessary documents, as ignoring these requirements can lead to future issues. For more effective documentation management tips, visit our website.

Avoiding MIPS Submission Mistakes

To maximize your practice’s performance and avoid penalties, avoid common errors in MIPS submission. Understand pitfalls and implement suggested fixes to streamline reporting. Focus on thriving in the complex landscape, not just meeting minimum requirements. Review submission strategies, educate the team, and stay updated on MIPS changes. A proactive approach can turn potential challenges into opportunities for improvement and success.