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Proposed Rule for MIPS 2023 Performance Year: Promoting Interoperability, Improvement Activities and QPP Public Reporting


The Proposed Rule for the 2023 Performance Year was released in late July. Practices are encouraged to comment on any of the proposed changes that may negatively impact your practice – either in reimbursement or increased administrative burdens.

As a part of a recent webinar, the Quality Reporting Engagement Group highlighted the proposed changes to the Merit-based Incentive Payment System (MIPS) program for the 2023 Performance Year.

Promoting Interoperability

The Centers for Medicare & Medicaid Services (CMS) is proposing to remove the automatic reweighting for certain Eligible Clinicians including nurse practitioners, physician assistants; certified registered nurse anesthetists; and clinical nurse specialists. If your practice has any of these types of Eligible Clinicians in your practice, it is suggested to review the Final Rule to see if the automatic reweighting is discontinued for them.

With the automatic reweighting, CMS is proposing to do a voluntary reporting option for PI at the APM Entity level. If you do not choose to report under the APM Entity level, you will be continued to score at the roll-up calculation described in the previous rule.

CMS is also modifying the levels of active engagement for the Public Health and Clinical Data Exchange Objective. In 2022, CMS made reporting mandatory for the Vaccines and Immunizations and Electronic Case Reporting (eCR) measures. There were three options for engagement. They are proposing to combine Options 1 and 2 into a single option titled “Pre-production and Validation” and rename Option 3 “Validated Data Production” as the two options to be reported. CMS will require a Yes/No answer and ask for which option you are using. Practices are encouraged to stay in touch with their Public Health Agency to ensure they are doing all the necessary tasks to stay active.

Another proposed change is the Query of Prescription Drug Monitoring. CMS is proposing to make it required, and include Schedule II, III and IV opioid drug classes, beyond just Schedule II. They are also considering adding exclusions to this reporting measure. The measure would be worth 10 points.

CMS is proposing to add a third option for the Health Information Exchange (HIE) objective to give some practices some more options for becoming involved with an HIE. Practices can search on the web for Trusted Exchange Framework and Common Agreement (TEFCA) to understand the proposal and what this entails for the future.

With the measure additions and changes, the point structure for Promoting Interoperability will be adjusted. Practices are encouraged to review the measures and points for the 2022 Performance Year to the ones proposed for the 2023 Performance Year.

Improvement Activities Category

CMS did not make a lot of changes to the Improvement Activities Category – more were just changes to the activities themselves. Health equity is a focus of CMS for reporting and reimbursement, so the activities changed are related.

Six existing Improvement Activities are proposed to be removed, five will be modified and four were proposed to be added. Practices should review the inventory when the Rule is finalized to ensure they are not reporting on activities that were modified or removed.

Quality Payment Program Public Reporting

The Physician Compare website under the Quality Payment Program (QPP), lists providers and practices who currently are enrolled in the Medicare program and CMS quality programs, and is used by patients to find information on those providers.

CMS is proposing to include Publicly Reporting Utilization Data, including the procedures an individual clinician performs to make it easier for patients to find providers who will perform specific procedures; and Publicly Reporting Telehealth Indicators on clinician and group profile pages to “help empower patients’ healthcare decisions.”  CMS hopes this information will help the Physician Compare site gain more traffic.

The Quality Reporting Engagement Group partners with practices from helping choose the performance measure activities to submission, and even during an auditing process. With a combined 30+ years of experience, their team of experts understands regulatory changes and supports your Eligible Clinicians in successfully meeting MIPS measures. For answers to any questions, contact the team at