American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Reporting for Promoting Interoperability

MIPS 2018 Advancing Care Information ComponentThe Promoting Interoperability (PI; formerly the Advancing Care Information) component is worth 25 percent of the MIPS Final Score. The primary assessment for PI is a composite score composed of three parts: A Base score, a Performance score, and a Bonus score. To receive credit for the PI component in 2018, one must have either 2014 or 2015 edition certified electronic health record technology (CEHRT) and report their performance for a minimum of a continuous 90-day period. Additionally, providers are required to complete the “Prevention of Information Blocking Attestation.”

The Base score accounts for 50 percent of the score for the PI component and takes an all-or-nothing approach, requiring performance on at least one patient or attesting yes for each of four to five measures. Achieving the Base score is required before any score can be accrued for the performance portion.

One of the Base measures, the security risk analysis, created the most challenges for providers under the EHR Incentive Program (Meaningful Use), forcing providers to return their incentive payments and setting them up for future audits. The Office of the National Coordinator for Health IT (ONC) Office for Civil Rights has many resources on how to fulfill the Security Risk Analysis.

If the Base measures are satisfied, surgeons also can earn up to 90 percentage points under the Performance score, which is driven by the performance rate for each base measure reported, as well as additional measures voluntarily reported by the clinician.

There are also opportunities for clinicians to earn bonus points (up to 25 percent) for the PI performance category:

  • 10 percent bonus for submitting data for PI measures using 2015 Edition CEHRT exclusively
  • 10 percent bonus for reporting certain Improvement Activities via CEHRT
  • 5 percent bonus for reporting to an additional public health agency or clinical data registry not reported under the Performance score

When combined, the total achievable percentage points is 165 percent, but the PI component is capped at 100 percent, meaning there are multiple opportunities for extra credit to earn a perfect score.

Providers may meet criteria for exceptions from the PI component entirely. CMS will reweight the PI component to 0 percent and reallocate its weight (25 percent) to the Quality component for surgeons who meet one of the criteria below:

  • Small practices (solo practitioners or groups of 15 or fewer eligible clinicians)
  • Hospital-based MIPS eligible clinicians
  • Ambulatory Surgical Center (ASC)-based MIPS-eligible clinicians (note this policy was finalized to begin starting in 2017)
  • MIPS eligible clinicians whose EHR was decertified during the performance year or the year before the current performance year

Providers can determine if they are classified as a small practice or are considered hospital-based by using the MIPS Participation Status tool. Providers that are hospital-based or ASC-based will receive an automatic reweighting. Providers that are a small practice or whose EHR was decertified must apply for a hardship exception through the Hardship Application.

In order for a provider to meet the 15 point performance threshold for 2018 exclusively using the PI category, a surgeon must score 60 percentage points within the PI section (60*.25=15). If a surgeon completely reports the PI Base score measures, they will earn 50 PI percentage points, which translates to 12.5 points in the final score (50*.25=12.5). To earn the additional 2.5 points necessary to get to 15 for the PI section, surgeons need to acquire an additional 10 percentage points in the Performance measures. This can be achieved by performing at a rate of 91 to 100 percent on a single measure. It is important to note Base measures may be used to earn performance points. Thus, surgeons may not need to select an additional measure, but rather simply need to perform well on those Base score measures that also provide credit in the performance score.