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Centers for Medicare & Medicaid Services Quality Payment Program. Small Practices Newsletter
Quality Payment Program Small Practices Newsletter: August 2024

The Quality Payment Program (QPP) Small Practices Newsletter is a monthly resource that provides small practices (15 or fewer clinicians) with program updates, upcoming QPP milestones, and resources to support their continued participation and success in QPP. 

Please share this newsletter with your fellow clinicians and practice staff and encourage them to sign up [ https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12879%2F&utm_source=newsletter&utm_medium=email&utm_id=newsletter_june2023&utm_content=smallpracsignup ] to receive this monthly resource.

*At-a-Glance: Required and Recommended Activities for Successful Participation in QPP *

Each month, we share required and recommended activities for small practices to support their successful participation in QPP. The activities follow a rolling quarter approach, letting you see activities for the previous month, the current month, and the following month.

Small Practices Newsletter Timeline Graphic

*In This Issue:                                                                                 *


* *Hot Topics: What You Need to Know*
* Now Available: 2023 MIPS Performance Feedback and Final Score and 2025 MIPS Payment Adjustment Information [ #link_1 ]
* Now Available: 2023 Targeted Review [ #link_2 ]
* Submit Comments on Policy Changes for Quality Payment Program in Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule by September 9, 2024 [ #link_3 ]
* Update to 2024 Automatic Extreme and Uncontrollable Circumstances (EUC) Policy for Public Health Emergency (PHE) in Texas [ #link_4 ]
* Additional Procedures Data Now Available on Medicare.gov Compare Tool [ #link_5 ]
* QPP Feedback Opportunity: Tell Us About Your 2023 Performance Year Final Feedback Experience [ #link_6 ]
* Updated Resource Available: Small Practice Action Planning Tool and Video [ #link_7 ]
* Relevant Resources [ #link_8 ]
* Need Assistance? [ #link_9 ]

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Now Available: 2023 MIPS Performance Feedback and Final Score and 2025 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) released the Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2023 performance year and associated MIPS payment adjustment information for the 2025 payment year.


* Your 2023 final score determines the payment adjustment you’ll receive in 2025; a positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished in 2025.
* *REMINDER:* *There’s no exceptional performance adjustment for the 2023 performance year/2025 payment year. *Congressional funding for the additional adjustment for exceptional performance expired after the 2022 performance year/2024 payment year.

*How Do I Access Feedback?*


* Sign in [ https://qpp.cms.gov/login ] to the QPP website using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) system credentials; these are the same credentials that allowed you to submit your 2023 MIPS data.
* Click “View Feedback” on the home page and select your organization (Practice, Alternative Payment Model (APM) Entity, Virtual Group).
* Practice representatives can access individual, subgroup, and group feedback.
* Third party representatives can’t access final feedback or payment adjustment information.

If you don’t have a HARP account or QPP role, please refer to the *Register for a HARP Account* (re: HARP account) and *Connect to an Organization* (re: QPP role) documents in the QPP Access User Guide (ZIP, 4MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2955/QPP-Access-User-Guide.zip ] and start the process now.

*Performance Feedback Resources:*


* *2023 MIPS Performance Feedback FAQs (PDF, 3MB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2950/2023-MIPS-Performance-Feedback-FAQs.pdf ] – Reviews the information available in performance feedback and how to access it.
* *2023 MIPS Performance Feedback Supplemental Reports Guide (PDF, 824KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2914/2023-MIPS-Performance-Feedback-Supplemental-Reports-Guide.pdf ] – Reviews the downloadable supplemental and patient-level reports for administrative claims quality and cost measures.
* *2025 MIPS Payment Year Payment Adjustment User Guide (PDF, 710KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2962/2025-MIPS-Payment-Adjustment-User-Guide.pdf ] – Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions.
* *2023 Quality and Cost Benchmarks* [ https://qpp.cms.gov/benchmarks ]– Links to the Benchmarks page of the QPP website where users can download the 2023 quality and cost benchmarks files and supporting documentation.

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Now Available: 2023 Targeted Review

Review your MIPS performance feedback, including your MIPS final score and payment adjustment factor(s), on the QPP website [ https://qpp.cms.gov/login ].


* Individual clinicians, groups, subgroups, virtual groups, APM Entities (including Medicare Shared Savings Program ACOs), designated support staff and authorized third party intermediaries may request that CMS review the calculation of their MIPS payment adjustment factor(s) through a process called targeted review.

*When to Request a Targeted Review*

If you believe there’s an error in the calculation of your MIPS payment adjustment factor(s), you can request a targeted review *now until October 11, 2024, at 8 p.m. ET*.

For example:


* Data were submitted under the wrong Taxpayer Identification Number (TIN) or National Provider Identifier (NPI).
* You have Qualifying APM Participant (QP) status and shouldn’t receive a MIPS payment adjustment.
* Performance categories weren’t automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances.

*Note: *This isn’t a comprehensive list of circumstances. If you have questions about whether your circumstances warrant a targeted review, please contact the QPP Service Center by phone at 1-866-288-8292 (Telecommunications Relay Service (TRS): 711) or by email at QPP@cms.hhs.gov.  

*How to Request a Targeted Review*

You can access your MIPS final score and performance feedback and request a targeted review:


* Sign in [ https://qpp.cms.gov/login ] using your HARP credentials (ACO-MS credentials for Shared Savings Program ACOs); these are the same credentials that allowed you to submit your 2023 MIPS data.
* Click “Targeted Review” on the left-hand navigation.

CMS generally requires documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required. If the targeted review request is approved and results in a scoring change, we’ll update your final score and/or associated payment adjustment (if applicable), as soon as technically feasible. *Please note that targeted review decisions are final and _not_ eligible for further review.*

*Targeted Review Resources:*


* *2023 Targeted Review User Guide (PDF, 15MB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2961/2023-Targeted-Review-Guide.pdf ] – Reviews the process for requesting a targeted review and examples for when you would or wouldn’t request a targeted review.
* *2025 MIPS Payment Year Payment Adjustment User Guide (PDF, 710KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2962/2025-MIPS-Payment-Adjustment-User-Guide.pdf ] – Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions.

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Submit Comments on Policy Changes for Quality Payment Program in Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule by September 9, 2024

*CMS Proposes Policy Changes for QPP*

CMS issued its Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Notice of Proposed Rulemaking [ https://www.federalregister.gov/documents/2024/07/31/2024-14828/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule-and-other ], which includes proposed policies for QPP. 

The Notice of Proposed Rulemaking (NPRM) includes proposals for MIPS and Advanced APMs, as well as several Requests for Information (RFIs).

Specifically, we’re proposing policies that:


* Continue the development and maintenance of MIPS Value Pathways (MVPs).
* Establish the APM Performance Pathway (APP) Plus quality measure set.
* Update the MIPS measure/activity inventories and scoring methodologies.

Finally, we’re proposing a small number of policies intended to maintain stability within the MIPS program through the established performance threshold and data completeness criteria.

*2025 Policy Highlights*

Key QPP policies that we’re proposing in the 2025 PFS Proposed Rule include:


* Introducing *6 new MVPs for the 2025 performance period *that are related to ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care.
* Creating APP Plus, an *additional quality measure set under the APP*, which would include the 6 measures currently in the APP quality measure set and incrementally incorporate the remaining 5 Adult Universal Foundation quality measures (for a total of 11 measures by the 2028 performance period/2030 payment year).
* *Maintaining the current performance threshold policies*, leaving the performance threshold at *75 points *for the 2025 performance period.
* *Keeping the 75% data completeness criteria *through the 2028 performance period.

*Overview of RFIs*

We’re also seeking feedback on RFIs about the following topics:


* MVP adoption and subgroup participation
* Public Health and Clinical Data Exchange Objective under the Promoting Interoperability performance category
* Guiding principles for the development of patient-reported outcome quality measures
* Changes to the administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey

*Comment Submission Period*

CMS encourages you to submit comments on these proposals.

You must officially submit your comments in one of the following ways: 


* *Electronically *– You may submit electronic comments through regulations.gov [ https://www.regulations.gov/ ].
* *Regular mail *– You may mail written comments to the following address ONLY: 

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS‑1807-P, P.O. Box 8016, Baltimore, MD 21244-8016. *Please allow sufficient time for mailed comments to be received prior to the end of the comment period.* 


* *Express or overnight mail *– You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1807-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244‑1850.

*Please note:* FAX transmissions won’t be accepted. 

The 60-day comment period for the 2025 PFS Proposed Rule is open until *5 p.m. ET on September 9, 2024*.

*For More Information*

Learn more about the QPP proposals by reviewing the following QPP policies in the CY 2025 Medicare PFS Proposed Rule Resources:


* *2025 Quality Payment Program Proposed Rule Fact Sheet and Policy Comparison Table (PDF, 596KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2876/2025-QPP-Proposed-Rule-Fact-Sheet-and-Policy-Comparison-Table.pdf ]– Provides an overview of QPP proposals and RFIs included in the CY 2025 Medicare PFS Proposed Rule, and a comparison table contrasting existing policies with proposals.
* *2025 Proposed and Modified MVPs Guide (PDF, 948KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2877/2025-Proposed-and-Modified-MVPs-Guide.pdf ] – Highlights newly proposed MVPs and modifications to previously finalized MVPs, beginning with the 2025 performance year.

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Update to 2024 Automatic Extreme and Uncontrollable Circumstances (EUC) Policy for Public Health Emergency (PHE) in Texas

In response to Hurricane Beryl, as identified by both a Health and Human Services (HHS) Public Health Emergency (PHE) declaration (Texas [ https://aspr.hhs.gov/legal/PHE/Pages/Beryl-July2024.aspx ]) and a Federal Emergency Management Agency (FEMA) disaster declaration (DR-4798-TX [ https://www.fema.gov/disaster/4798 ]), CMS has determined that the MIPS automatic EUC policy will apply to MIPS eligible clinicians in designated affected counties of Texas.

MIPS eligible clinicians in these areas will be automatically identified and have all 4 performance categories reweighted to 0% during the data submission period for the 2024 performance period (January 2 to March 31, 2025). This will result in a score equal to the performance threshold, and they'll receive a neutral payment adjustment for the 2026 MIPS payment year.

However, if MIPS eligible clinicians in these areas submit data on 2 or more performance categories, they’ll be scored on those performance categories and receive a 2026 MIPS payment adjustment based on their 2024 MIPS final score.

*Note:* The MIPS automatic EUC policy doesn’t apply to MIPS eligible clinicians participating in MIPS as a group, subgroup, virtual group, or APM Entity. However, groups, virtual groups, and APM Entities can request reweighting through the EUC Exception application. Subgroups will inherit any reweighting approved for their affiliated group; they can’t request reweighting independent of their affiliated group’s status.

*For More Information*

Please reference the MIPS EUC Exception section on the Quality Payment Program Exception Applications webpage [ https://qpp.cms.gov/mips/exception-applications?py=2024 ] and review the 2024 MIPS Automatic EUC Policy Fact Sheet (PDF, 352KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2840/2024-MIPS-Automatic-EUC-Policy.pdf ].

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Additional Procedures Data Now Available on Medicare.gov Compare Tool

As part of CMS’ ongoing effort to inform patients and caregivers about clinicians’ experiences, CMS has added new procedures to the utilization data on the Medicare.gov compare tool’s [ https://www.medicare.gov/care-compare/ ] profile pages for doctors and clinicians.

In January 2024, CMS added the first procedure volume data [ https://data.cms.gov/provider-data/topics/doctors-clinicians ] file with information for 12 procedures publicly reported on Medicare.gov compare tool profile pages for doctors and clinicians:


* Hip replacement
* Knee replacement
* Spinal fusion
* Cataract surgery
* Colonoscopy
* Hernia repair – groin (open)
* Hernia repair (minimally invasive)
* Mastectomy
* Coronary artery bypass graft (CABG)
* Pacemaker insertion or repair
* Coronary angioplasty and stenting
* Prostate resection

The July 2024 release expanded the list of procedures to include:


* Upper endoscopy
* Arthroscopy – upper extremity
* Arthroscopy – lower extremity
* Varicose vein ablation
* Laminectomy/laminotomy (lumbar)
* Lower limb revascularization

The procedures added to profile pages were performed by doctors and clinicians for Original Medicare and Medicare Advantage patients in the previous 12 months, after allowing a 3-month claim processing period (for example, claims for dates of service occurring between January 1, 2023, and December 31, 2023, that were processed by April 1, 2024). CMS will continue to add more procedures to Medicare.gov compare tool profile pages periodically, as feasible.

The Utilization (Procedure Volume) Data Published on the Compare Tool on Medicare.gov July 2024 Fact Sheet (PDF, 386.64KB) [ https://www.cms.gov/files/document/utilization-procedure-volume-data-published-compare-tool-medicaregov-fact-sheet-july-24-38664-kb.pdf ] on the Care Compare: Doctors and Clinicians Initiative page [ https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/care-compare-dac-initiative ] provides the full list of procedures and background information about CMS’ reporting of procedure volume data. The current procedure volume data file is available as part of the doctors and clinicians datasets [ https://data.cms.gov/provider-data/search?theme=Doctors%20and%20clinicians ].

If you have any questions about public reporting for doctors and clinicians on the Medicare.gov compare tool [ https://www.medicare.gov/care-compare/ ], contact the QPP Service Center.

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QPP Feedback Opportunity: Tell Us About Your 2023 Performance Year Final Feedback Experience

*Did you view your 2023 Performance Year Final Scores and feedback from QPP?*

*We Want to Hear From You*

*Follow this link to take the survey* [ https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fagilesix.qualtrics.com%2Fjfe%2Fform%2FSV_26qmpfd92s7wwoC&data=05%7C02%7Ctdaniels%40air.org%7C7caf322d210047985a1708dcb0ab27de%7C9ea45dbc7b724abfa77cc770a0a8b962%7C0%7C0%7C638579496372199687%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=DHhoKxJzxhxh4LTUYFGnZx%2Flml0JfaArjmr5h61cLTc%3D&reserved=0 ]

The goal of this survey is to help CMS better understand the experiences of QPP participants who have received final scores for the 2023 performance year. Your responses will help CMS identify how the final feedback process can be improved, as well as what’s working well.

Results will be reported in such a way that no single individual, group, or entity can be identified. This survey is conducted by outside contractors, and participation is completely voluntary and confidential. Your decision to participate or not to participate in this survey won’t affect any pending or future determinations. This survey should take no more than 15 minutes to complete.

Your feedback is essential to understand how we can best serve QPP participants. Eligible clinicians who complete this survey may receive an improvement activities credit. If you have any questions, please reach out to qppuserresearch@cms.hhs.gov.

Thank you for your feedback.

Interested in participating in upcoming research with the QPP Human-Centered Design Team? Fill out this survey [ https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fagilesix.qualtrics.com%2Fjfe%2Fform%2FSV_6MyNkgZfHGpG18y&data=05%7C02%7Ctdaniels%40air.org%7C7caf322d210047985a1708dcb0ab27de%7C9ea45dbc7b724abfa77cc770a0a8b962%7C0%7C0%7C638579496372210476%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=rMCJlQdb4JtHlAUjfsrgZrUPTTnePM1MP3VMHmraOpY%3D&reserved=0 ] to be added to our QPP user research contact list.

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Updated Resource Available: Small Practice Action Planning Tool and Video

This 2024 Small Practice Action Planning Tool (PDF, 1MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2954/2024-Small-Practice-Action-Planning-Tool.pdf ] is for small practices interested in examining their MIPS final score to identify opportunities to improve performance in the next performance year. This resource is accompanied by the Introduction to the Small Practice Action Planning Tool (VIDEO) [ https://youtu.be/4UBAW45RlHk ].

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Relevant Resources

*2024 Small Practice Resources*

2024 Small Practice Action Planning Tool (PDF, 1MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2954/2024-Small-Practice-Action-Planning-Tool.pdf ]

Introduction to the Small Practice Action Planning Tool (VIDEO) [ https://youtu.be/4UBAW45RlHk ]

2024 MIPS At-A-Glance Reporting Options for Small Practices (PDF, 260KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2929/2024-MIPS-At-A-Glance-Reporting-Options-for-Small-Practices.pdf ]

2024 MIPS Quick Start Guide for Small Practices (PDF, 1MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2622/2024MIPSGuideforSmallPractices.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=february+2024&utm_id=newsletter_february2024&utm_content=24mipsguidesp ]

MIPS 2024 Small Practice Eligibility and Participation FAQs (PDF, 461KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2729/2024-Small-Practice-Eligibility-FAQs.pdf ]

Do I Need to Participate in MIPS? How to Check Eligibility Status (VIDEO) [ https://www.youtube.com/watch?v=rHoH4hJaetI ]

Small Practices FAQs [ https://qpp.cms.gov/resources/small-underserved-rural-practices#:~:text=Service%20Center%20Ticket-,FAQs,-Am%20I%20eligible ] [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2657/2024What%27sNewforSmallPractices.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=february+2024&utm_id=newsletter_february2024&utm_content=24whatsnewsp ]

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Need Assistance?

Contact the QPP Service Center by email at QPP@cms.hhs.gov, by creating a QPP Service Center ticket [ https://cmsqualitysupport.servicenowservices.com/ccsq_support_central?utm_source=newsletter&utm_medium=email&utm_id=newsletter_september2023&utm_content=ccsqsupport ], or by phone at 1-866-288-8292 (Monday – Friday, 8 a.m. – 8 p.m. ET).

To receive assistance more quickly, please consider calling during non-peak hours — before 10 a.m. and after 2 p.m. ET.

People who are deaf or hard of hearing can dial 711 to be connected to a TRS Communications Assistant.

QPP Footer 2023 [ https://qpp.cms.gov/resources/help-and-support ]


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