With each reporting year, CMS makes changes to MIPS reporting requirements. Some are regulatory changes that are required based on timelines set in the MACRA law and others are designed to improve QPP reporting while reducing administrative burden for clinicians. This blog will cover some of the top changes affecting clinicians in reporting year 2024.
- Data Completeness increased to 75%: Data completeness is the percentage of eligible denominator cases for which a group or eligible clinician has reported performance data. In 2023, the data completeness threshold was 70%. This has increased to 75% in 2024. Failure to meet data completeness will result in no score on that quality measure unless you’re an eligible clinician or group in a small practice (15 or fewer eligible clinicians) which will then earn 3 points.
- Automatic Reweighting of Promoting Interoperability Category: Beginning in 2024, the following clinician types will no longer be automatically reweighted and are therefore required to report Promoting Interoperability data – physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dietitians or nutrition professionals. The only clinician types who qualify for automatic reweighting in 2024 are clinical social workers and those with a special status that allows for reweighting (ambulatory surgical center (ASC)-based, hospital-based, non-patient facing, and small practices). Failure to report Promoting Interoperability when required will result in a 0 score for this category and make it more difficult to get to the 75-point threshold to avoid a negative adjustment.
- Promoting Interoperability performance period increased to 180 days: In previous years, the measures in the Promoting Interoperability performance category were only required to be tracked for a consecutive 90-day period. Beginning in 2024, the Promoting Interoperability performance period increases to a consecutive 180-day performance period. This means groups and eligible clinicians must begin their performance period no later than July 5, 2024 in order to earn any points for this category.
- Data submission of MIPS eCQMs for quality must be submitted using CEHRT: Any MIPS eligible clinicians who report eCQMs for quality reporting must use certified electronic health record technology (CEHRT) for calculation and submission of measures. CMS stresses this requirement has been their intention all along, but they feel the message was lost once the electronic end-to-end reporting bonus was sunset. If you currently use eCQMs for quality, make sure your vendor has the appropriate CEHRT certifications required by CMS before the end of the reporting year.
- Looking forward to 2025 – Removal of Health IT Vendor as a third-party intermediary: Beginning in the 2025 performance year, CMS has removed Health IT Vendors from being able to submit data on behalf of MIPS eligible clinicians. Moving forward, any vendor who submits data on behalf of an eligible clinician or group must self-nominate and be granted approval to operate as a Qualified Registry or QCDR. Health IT Vendors may still provide their technology for clinicians to assist with reporting under MIPS with the understanding that the clinicians submit their own reporting data to CMS. How does this affect you? If you are currently submitting your MIPS data through a vendor who is not a Qualified Registry or QCDR, you should ask that vendor if they plan to self-nominate before next year. If they don’t, this allows you time to find a new vendor.
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