CMS Rules for 2021: Key Takeaways on Telehealth, PI Program and Other Rule Provisions

Emids

Oct 2, 2020

CMS held off on making any major changes as it relates to quality reporting under the physician fee schedule (PFS) for the quality payment program (QPP) and under the inpatient prospective payment system (IPPS) for the inpatient quality reporting (IQR) program. As organizations look towards 2021, while there are no substantive changes, they will need to consider the following implications:

Public reporting of electronic clinical quality measure (eCQM) data – CMS has finalized making eCQMs public which means now is the time to ensure the data is being captured accurately.
Increased number of calendar quarters for eCQM submissions.
Transitioning to a combined chart-abstracted and eCQM validation process – those eCQMs are starting to really be put to the test.
Proposal to permanently expand some telehealth services and no longer reimburse for other telehealth services after the public health emergency is resolved.
Planning for transition to the 2015 Edition Cures Update.

About the CMS Rules

On August 4, 2020, the Centers for Medicare and Medicaid Services (CMS) filed the Medicare Program Physician Fee Schedule (PFS) proposed rule. It was published in the Federal Register on August 17, 2020; comments are due on October 5, 2020; and the final rule is expected to be published around the first of November. We refer to this rule as the CY 2021 PFS Proposed Rule.

On September 2, 2020, CMS filed the FY 2021 Medicare Program Hospital Inpatient Prospective Payment Systems (IPPS) final rule. The Federal Register publish date was September 18, 2020. We refer to this rule as the FY 2021 IPPS Final Rule.

In this blog, we provide a summary of finalized quality reporting updates for the hospital Medicare and Medicaid Promoting Interoperability (PI) programs and the Medicare IQR program. Our focus is on the reporting requirements for the PI objective measures and electronic clinical quality measures (eCQMs). Content is based on the fiscal year (FY) 2021 IPPS final rule with insights from eMRB subject matter experts. Additionally, we provide a summary of QPP and telehealth updates as proposed in the CMS CY 2021 PFS Proposed Rule.

FY 2021 IPPS Final Rule Provisions

Requirements for PI and IQR Programs

As CMS looks toward the future of the Promoting Interoperability Program, the general goals include reducing administrative burden, supporting alignment with the Quality Payment Program and the 21st Century Cures Act, advancing interoperability and the exchange of health information, and promoting innovative uses of health IT. In the finalized provisions, CMS is holding true to gradually increasing the reporting timeframe of electronic quality reporting and aligning requirements within the IQR and the PI programs.

Key Areas of Interest

The most significant quality reporting updates in this rule are for eCQMs. For the PI and IQR program, CMS is requiring a yearly increase in number of quarters for eCQM reporting and they will begin publicly reporting eCQM data by 2022. CMS is integrating the validation processes for chart-abstracted measures and eCQMs, and there are minor modifications to the PI Program objective measures. For the IQR program, CMS is establishing certified EHR technology (CEHRT) requirements for the hybrid measures.

Updates for the Medicare PI program

1. Electronic Prescribing Objective measure: Query of Prescription Drug Monitoring Program (PDMP). CMS will continue counting the e-Prescribing Query of PDMP measure as optional for the CY 2021 reporting year; it will be worth 5 bonus points.

2. Health Information Exchange (HIE) measure: Support Electronic Referral Loops by Receiving and Incorporating Health Information. CMS changed the name of the HIE 2 measure to: Support Electronic Referral Loops by Receiving and Reconciling Health Information. As a reminder, reporting on this measure is a requirement as there is no longer an exclusion for this measure.

Updates for the Medicare PI Program and the IQR Program

1. Public reporting of eCQM data. CMS will begin publicly reporting eCQM performance data as early as the Fall of 2022 based on the CY 2021 reporting year data.

2. Number of eCQM reporting quarters. CMS will progressively increase the number of quarters for hospitals to report eCQM data over a 3-year period.

CY 2020 reporting year: 1 self-selected calendar quarter of data
CY 2021 reporting year: 2 self-selected calendar quarters of data
CY 2022 reporting year: 3 self-selected calendar quarters of data
CY 2023 reporting year: 4 self-selected calendar quarters of data

3. Number of eCQM measures. For CY 2021 reporting period, the eCQM list and number of measures remain the same as for 2020. Beginning with CY 2022 reporting period, hospitals will be required to report three self-selected eCQMs, and the Safe Use of Opioids – Concurrent Prescribing eCQM (Safe Use eCQM), for a total of four eCQMs.

4. QRDA I File Identification. CMS has finalized to add a fifth key element for file identification beginning with the CY 2021 reporting period. This additional element is intended to prevent the risk of a previously submitted file by a different vendor unintentionally being overwritten. Hospitals will be required to incorporate the following 5 elements in their QRDA I file:

CMS Certification Number (CCN)
CMS Program Name
EHR Patient ID
Reporting period specified in the Reporting Parameters Section
EHR Submitter ID (new element)

5. Validation Process. CMS is streamlining the validation process beginning with FY 2022 Reporting Year / FY 2024 Payment Determination.

Chart abstraction will require use of electronic file submissions via a CMS-approved secure file transmission process beginning with validation affecting the FY 2024 payment determination, which is Q1 of CY 2021.
The combined validation process for the chart-abstracted measures and eCQMs
1. Updates the quarters of data required for validation for both chart-abstracted measures and eCQMs
2. Expands targeting criteria to include hospital selection for eCQMs
3. Changes the validation pool from 800 hospitals to 400 hospitals
4. Removes the current exclusions for eCQM validation selection
5. Requires electronic file submissions for chart-abstracted measure data
6. Aligns the eCQM and chart-abstracted measure scoring processes
7. Updates the educational review process to address eCQM validation results

Update on Hybrid Measures for the Hospital IQR Program

1. Beginning with FY 2026 Payment Determination, CMS will continue the policy that requires hospitals to use EHR technology certified to the 2015 Edition to submit data on the Hybrid Hospital-wide Readmission (HWR) with Claims measure. Additionally, they have expanded this requirement to any future hybrid measures adopted into the Hospital IQR Program’s measure set.

2. In the CMS CY 2021 PFS proposed rule, CMS has proposed to allow hospitals to use either: (1) technology certified to the 2015 Edition criteria for CEHRT for reporting eCQMs and hybrid measures or (2) technology certified to the 2015 Edition Cures Update standards as finalized in the 21st Century Cures Act final rule (85 FR 50271).

3. The core clinical data elements and linking variables must be submitted using the Quality Reporting Document Architecture (QRDA) I file format for the Hybrid HWR measure and future hybrid measures in the program.

So, what does this all mean?

As stated in the beginning, there are no big changes but below are some potential implications to consider in planning for the quality reporting updates.

eCQM Public Reporting. Public reporting of eCQM data will require additional eCQM data review time and potential updates to the processes for monitoring and managing quality data outcomes to ensure the right data elements are captured.
eCQM Reporting Periods. The increased number of reporting periods will require a higher level of coordination with vendors to provide timely QRDA I reports.
QRDA I File Identification. Organizations will need to verify and validate that their vendors have incorporated the new EHR Submitter ID element by the CY 2021 reporting period.
Query of PDMP Measure. Even though this measure has been retained as a 5-point bonus, it’s important to note that CMS is working via the SUPPORT Act enacted in 2018 to include requirements to federally fund PDMP enhancements. Efforts are underway to look at a more robust and standardized approach to EHR/PDMP integration. Organizations need to be aware of the level their vendors and state are pursuing these activities.
Chart-abstraction CQM Validation Process. Beginning with Q1 2021, the options to submit paper copies, CD, DVD, or flash drives are no longer accepted formats. Hospitals will need to ensure that hospital medical records for validation of chart-abstracted measures are submitted as PDF copies using direct electronic file submission via a CMS approved secure file transmission (secure ftp) process.
Hybrid Measures Core Clinical Data Elements. While the Hybrid measure is not classified as an eCQM, the effort to map, extract and validate core clinical data elements from the EHR will be similar to eCQMs. As an example, hospitals over the years have added more values for labs and vital signs since the original EHR build, causing challenges in capturing all the right values when mapping the Hybrid measure. This takes some time and testing, which is one reason why CMS is giving hospitals the additional two years to address potential data collection issues before mandatory reporting is required.

CY 2021 PFS Proposed Rule Provisions

Key Provisions proposed for the QPP

This regulation contains updates to the Quality Payment Program (QPP) and includes the following proposed changes:

Delay of the implementation of Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) to 2022 instead of 2021. The MIPS Value Pathways is a new approach to the clinician-based quality reporting program. It is a subset of measures and activities from the 4 MIPS performance categories relevant to the population the clinicians are caring for, a specialty or medical condition.
Increase in the performance threshold from 45 points for the 2020 performance year to 50 points for 2021 (10 points less than the 60-point threshold finalized for 2021 in the CY 2020 PFS Rule).
Removal of the CMS Web Interface as a collection type and submission type for reporting MIPS quality measures beginning with the 2021 performance period.
A new Alternative Payment Model Performance Pathway (APP) for 2021 to align with the new MVP framework, this option would only be available to MIPS Alternative Payment Model (APM) participants and would be reported by the individual eligible clinician, group at the Taxpayer Identification Number (TIN) level, or APM entity.
Sunset the Alternative Payment Model (APM) Scoring Standard.

Proposed Telehealth Updates

At the onset of the COVID crisis, CMS relaxed many of the requirements for reimbursement of telehealth services. In the CY 2021 PFS Proposed rule, CMS outlines which of the expanded telehealth services should permanently be allowed after the COVID-19 crisis subsides and which services should not be reimbursed once the public health emergency is resolved. CMS also groups several telehealth services as requiring additional supportive documentation before determination can be made on whether these services should be permanently added. CMS is proposing to allow for the continued reimbursement of these services for one calendar year following the conclusion of the COVID-19 crisis to allow time for data gathering for the required analysis. CMS encourages practitioners and stakeholders to provide comments about their experiences with the relaxed telehealth guidelines to assist with determining which flexibilities should be made permanent. CMS will accept comments on the proposed rule until October 5, 2020. The following Fact Sheet: Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021 includes a listing of telehealth services CMS is seeking feedback on.

2015 Edition and the 2015 Edition Cures Update

In the CY 2021 PFS proposed rule, CMS begins using the term 2015 Edition Cures Update. This version of the 2015 Edition stems from the 21st Century Cures Act final rule that appeared in the May 1, 2020 Federal Register, which finalized a number of updates to the 2015 Edition of health IT certification criteria and is now referred to as the 2015 Edition Cures Update.

The 21st Century Cures Act final rule revises and adds new certification criteria that establish the capabilities and related standards and implementation specifications for the certification of health IT, as well as removes certain criteria. In the CY 2021 PFS proposed rule, CMS proposes to require that technology used to meet the CEHRT definitions must be certified in accordance with the updated certification criteria in the 21st Century Cures Act final rule. As such in the finalized FY 2021 IPPS Rule, CMS also mentions expanding the capabilities under the Hospital IQR Program to allow hospitals to use either (1) technology certified to the 2015 Edition criteria for CEHRT, or (2) technology certified to the 2015 Edition Cures Update standards.

Implications

The proposed rule introduced minimal changes to the QPP in an effort to reduce burden on providers as they continue to face challenges with COVID-19.
The postponed implementation of MVPs gives providers additional time to prepare for their participation in this pathway, which involves providing health IT capabilities and infrastructure components like those required for APMs. This would include performance measurement tracking; performance improvement processes; interoperability; data information systems that assist clinicians and practices in monitoring performance and adopting new workflows and care delivery methods; and capabilities to compile and analyze population health data (critical to assuming and managing risk).
Hospitals and providers should provide feedback to CMS before the October 5, 2020 deadline on the telehealth services they are currently providing as a result of the relaxed regulation to ensure their input will be taken into consideration as CMS formulates its new telehealth policy.
While health IT developers have up to 24 months from May 1, 2020 to make technology certified to the updated and/or new criteria available to their customers; organizations need to work with their vendors to ensure the requirements for the 2015 Edition Cures Updates are in progress.

Sources

FY 2021 IPPS Final Rule: Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Final Policy Changes and Fiscal Year 2021 Rates; Quality Reporting and Medicare and Medicaid Promoting Interoperability Programs Requirements for Eligible Hospitals and Critical Access Hospitals. Unpublished version filed on 9/2/2020; Published in Federal Register on 9/18/2020.
CMS Press Release: CMS Advancing Seniors’ Access to Cutting-edge Therapies and Technology in Medicare Hospital Rule
CMS Fact Sheet: Fiscal Year (FY) 2021 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Final Rule (CMS-1735-F)
CY 2021 PFS Proposed Rule: Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug under a Prescription Drug Plan or an MA-PD plan; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; and Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Unpublished version filed on 8/4/2020; Published in Federal Register on 8/17/2020.
CMS PFS Proposed Rule Fact Sheet: Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021
CMS QPP Fact Sheet: 2021 Quality Payment Program Proposed Rule Overview Fact Sheet

About Emids regulatory review board (EMRB)

Collaboration of content for this blog was provided by EMRB subject matter experts, covering important quality reporting topics for our customers and partners. Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time. For more information about these changes, contact us at engage@emids.com.