Background
The Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) replaced the flawed Sustainable Growth Rate (SGR) formula that, for many years, served as the underpinning of Medicare provider payment. CMS included audiologists as “eligible clinicians” in the QPP effective January 1, 2019, as well as speech language pathologists, physical therapists, occupational therapists, clinical psychologists and registered dietitians or nutrition professionals. Until 2019, the QPP was limited to physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists (or groups or virtual groups that include one of these clinicians).
There are two paths to participation in quality reporting under QPP: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs). MIPS will be the pathway likely most feasible and familiar for audiologists, as MIPS includes some former Physician Quality Reporting System (PQRS) measures that audiologists reported to CMS before the sunset of the PQRS program.
Audiologists required to report under MIPS will have payment adjustments up to + or – 9 percent for the 2024 performance year/2026 payment year. Successful reporting under MIPS may result in a payment bonus up to 9 percent. Conversely, failure to meet MIPS reporting benchmarks may result in up to a 9 percent reduction in reimbursement. Audiologists may also opt in to the program or voluntarily report, but under the opt in mechanism, audiologists will be subject to payment adjustments.
Check your participation status with CMS.
Required Participants
To be required to report in the QPP, clinicians must meet all of the following requirements:
- Clinicians or groups that have billed $90,000 or more in allowed charges under the Medicare Physician Fee Schedule (MPFS), furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare secondary Payer)
- Clinicians or groups that provide care to 200 or more Medicare Part B FFS beneficiaries
- Clinicians or groups that provide over 200 distinct procedures to Medicare Part B beneficiaries
Providers who are required to participate may submit data as an individual or as part of a group, including a virtual group. Individual clinicians are identified by a unique combination of individual National Provider ID (NPI) and Tax ID Number (TIN). Clinicians who assigned their Medicare billing rights to a group organizational TIN can submit their data either: as part of a group TIN, pooling all clinicians’ data; or as an individual.
Data Submission Mechanisms
When determining whether to submit data as an individual or as a group, there are multiple submission mechanisms:
- Qualified Clinical Data Registry (QCDR)
- Certified Electronic health record (EHR)
- Qualifying registry
- Claims
- CMS web interface
- Attestation
If you have an EHR vendor or participate in a registry, be sure to contact the vendor and registry to understand system capabilities, verify deadlines, and confirm they will be able to report your data to CMS.
MIPS Performance Categories
There are four performance categories that make up a provider’s final score. This final score determines the payment adjustment. For audiologists, reporting will be limited to the Quality, Clinical Improvement, and Promoting Interoperability categories. Promoting Interoperability is new for audiologists effective January 1,2024.
Quality
This performance category replaces PQRS. This category covers the quality of the care clinicians deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups. Providers are required to report on 6 quality measures for successful reporting. CMS places great emphasis on outcomes measures that are intended to influence patient care delivery and current and future provider reimbursement.
CMS has finalized an established measures set for audiologists to use for MIPS program reporting. Audiologists need to report on at least 6 measures. These measures are:
- #130 – Documentation of Current Medications in the Medical Record
- #134 – Preventive Care and Screening: Screening for Depression and FollowUp Plan
- #155 – Falls: Plan of Care
- #181 – Elder Maltreatment Screen and Follow-Up Plan
- #182 – Functional Outcomes Assessment
- #226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- #261 – Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
- #318 – Falls: Screening for Future Falls Risk
- #431 – Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
- #487 – Screening for Social Drivers of Health.
New for 2024 – #317, Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.
New for 2024 – #498, Community Service Provider: Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least 1 of their HRSNs within 60 days after screening.
2024 MIPS measure specifications were recently published on the CMS QPP website.
Promoting Interoperability (PI)
CMS re-named the Advancing Care Information performance category to Promoting Interoperability (PI) to focus on patient engagement and the electronic exchange of health information using certified electronic health record technology (CEHRT). This performance category replaced the Medicare EHR Incentive Program, commonly known as Meaningful Use. Audiologists were not included as participants in Meaningful Use and until January 1, 2024, were excluded from this category.
To access reporting requirements included in the Promoting Interoperability category, see 2024 Promoting Interoperability Measure Specifications (ZIP, 3MB)
Improvement Activities
This is a performance category that includes an inventory of activities that assess how providers improve care processes, enhance patient engagement in care, and increase access to care. The inventory allows a provider to choose the activities appropriate for their practices from categories such as enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.
To access the inventory of eligible activities, see Improvement Activities Performance Category: Traditional MIPS Requirements.
Cost
The cost of care (resource use) provided will be calculated by CMS based on Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. Audiologists are currently exempt from this category.
References
QPP Resource Library on cms.gov
CMS’s Physician Fee Schedule