Q&A: MIPS Reporting for 2017

Tags: TMF Health Quality Institute; Merit-based Incentive Payment System; MIPS; MIPS Submission Options; TMF MIPS Toolbox;

By TMF Health Quality Institute

Clinicians participating in the Merit-based Incentive Payment System (MIPS) path of the Quality Payment Program (QPP) must report their 2017 data to the Centers for Medicare & Medicaid Services (CMS) between Jan. 2 and March 31, 2018. (The data submission window for clinicians using the CMS Web Interface is Jan. 22 to March 16.) Following are answers to common questions about the reporting process.

Question: How many MIPS measures and activities do I need to report for the 2017 performance year?
Answer: For the 2017 transition year, clinicians may report using the test, partial-year or full-year option. Those who go beyond the test option can earn a positive payment adjustment. Minimum reporting requirements for each are:

  • Test (neutral payment adjustment): One Quality measure or Improvement Activity (IA) or four or five Advancing Care Information (ACI) measures (depending on Certified Electronic Health Record Technology edition).
  • Partial year (neutral or positive adjustment): 90 continuous days of data for six Quality measures (including one outcome or high-priority measure), one or two Improvement Activities (depending on the measure weight) and all ACI base measures.
  • Full year (positive adjustment): Same as partial year option with 12 months of data.

Q: How do I report my data?
A: Submission options vary by MIPS category. You must use one reporting option per category, although you can choose a different reporting method for each category.

MIPS Submission Options


  • Individuals:
    Qualified Registry, Qualified Clinical Data Registry (QCDR), Electronic Health Record (EHR) or claims
  • Groups:
    Qualified Registry, QCDR, EHR, Administrative claims (readmission measure only), CMS Web Interface (groups of 25 or more), Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS survey

Improvement Activities

  • Individuals:
    Qualified Registry, QCDR, EHR, attestation
  • Groups:
    QCDR, Qualified Registry, EHR, CMS Web Interface (groups of 25 or more), attestation

Advancing Care Information

  • Individuals:
    Qualified Registry, QCDR, EHR, attestation
  • Groups:
    Qualified Registry, QCDR, EHR, CMS Web Interface (groups of 25 or more), attestation

Q: How does QPP reporting differ from reporting for PQRS and Meaningful Use?
A: PQRS (Physician Quality Reporting System) and Meaningful Use (Medicare EHR Incentive Program for Eligible Professionals) required multiple systems for reporting data. The QPP uses one system for submitting data and satisfying reporting requirements. You can log in to this system through the CMS QPP website (https://qpp.cms.gov); the sign-in link is in the upper right corner. Your EHR vendor or registry also may submit data on your behalf separate from this system.

Q: Do I need to register to use the QPP submission system?
A: You must have an Enterprise Identity Management (EIDM) account (the same used with the CMS Enterprise Portal) for the online QPP submission system, including an appropriate user role associated with your organization. Learn about setting up an EIDM account or managing your EIDM account credentials here:

For help logging in to the CMS portal, contact the CMS QPP Service Center at QPP@cms.hhs.gov or 1-866-288-8292.

Q: How do individual clinicians submit claims data for the MIPS Quality category?
A: Individual clinicians (no groups) submit claims data using a special code. See details in this 2017 MIPS Quality Performance Category Claims Data Submission Fact Sheet.

Q: How will I know if I have submitted a sufficient number of claims with a specific Quality code?
A: On your remittance advice (RA)/Explanation of Benefits (EOB), a denial code of N620 indicates the Quality Data Codes (QDCs) are valid for the 2017 performance period. QDCs were known as “G” codes with PQRS; they now are referred to as CPT2 codes. The N620 code is an indicator the QDC codes are valid; it does not guarantee the QDC was correct, or that you met reporting thresholds. Keep track of submitted cases to verify QDCs reported against the remittance advice notice sent by the Medicare Administrative Contractor (MAC).

Q: How do we report using a qualified registry or a QCDR?
A: A qualified registry collects and submits data for the MIPS Quality, ACI and IA categories on your behalf. A QCDR extracts data from your EHR to report MIPS measures on your behalf. It also can submit QCDR measures (formerly known as non-MIPS measures).

Q: Is it too late to sign up to report by registry?
A: Check with your selected registry or one affiliated with your EHR. See CMS-approved registries at 2017 CMS-Approved Qualified Registries or 2017 CMS-Approved QCDRs.

Q: We collected data for our measures in our EHR. Now what do we do?
A: EHR files are saved in Quality Reporting Document Architecture (QRDA) format. The CMS QPP data submission system will recognize the file format and credit you with EHR reporting.

Q: How do I attest to MIPS IA and ACI measures?
A: This is completed by your registry or EHR vendor (if they offer the capability) or through the data submission section of the CMS QPP website. Note: There is no “submit” or “save” button in the QPP submission system. When you enter data, the system automatically updates your record. You can update your data any time during the submission window.

Q: Where can I get help?
A: TMF Quality Improvement Consultants are available to answer questions about MIPS reporting and the QPP. Contact TMF at 1-844-317-7609 or via live chat, Monday – Friday, 8 a.m. – 5 p.m. CT. You can also submit a TMF Request for Support or email QPP-SURS@tmf.org.

Clinicians in TMF’s region also have free access to the TMF MIPS Toolbox (www.bizmedtoolbox.com/TMF), an online application for managing MIPS requirements, tracking progress and submitting data directly to CMS. To learn more, see Remove the Guesswork from MIPS with Free Online Application.

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