The CMS is extending the CMS Web Interface as a collection type and submission type in traditional MIPS for registered groups, virtual groups and APM Entities with 25 or more clinicians for the 2022 performance year.
Quality Measure Benchmarks
After analyzing the available data, the CMS determined there was no need to use performance benchmarks exclusively or to use a different baseline period (such as CY 2019) to create historical benchmarks. The CMS will create historical benchmarks for the 2022 performance period, using data submitted for the 2020 performance period.
Improvement Activities Performance Category
The CMS is:
- Adding seven new improvement activities, three of which are related to promoting health equity
- Modifying 15 current improvement activities, 11 of which address health equity
- Removing six previously adopted improvement activities
Promoting Interoperability Performance Category
Public Health and Clinical Data Exchange Objective
The CMS is modifying the reporting requirements for the Public Health and Clinical Data Exchange Objective and requiring MIPS-eligible clinicians to report the following two measures (unless an exclusion can be claimed):
- Immunization Registry Reporting
- Electronic Case Reporting
Beginning with the 2022 performance period, the following measures are optional; clinicians, groups and virtual groups that report a “yes” response for any of these measures will earn five bonus points:
- Public Health Registry Reporting measure
- Clinical Data Registry Reporting measure
- Syndromic Surveillance Reporting measure
Promoting Interoperability Measures
- The CMS did not finalize the proposal to modify the Provide Patients Electronic Access to Their Health Information measure to require patient health information to remain available to the patient (or patient-authorized representative) indefinitely, starting with a date of service of Jan. 1, 2016.
- The Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) is a new, required measure in which MIPS-eligible clinicians must attest to conducting an annual assessment of the High Priority Guide of the SAFER Guides.
- For the Electronic Case Reporting measure, the CMS is adding a fourth exclusion (in addition to the existing exclusion criteria) for PY 2022 only: Uses certified electronic health record technology (CEHRT) that isn’t certified to the electronic case reporting certification criterion at 45 CFR 170.315(f)(5) prior to the start of the performance period they select in CY 2022.
Attestations
The CMS modified the required Prevention of Information Blocking attestation statements.
Promoting Interoperability Reweighting
In addition to the existing special statuses/clinician types, the CMS will apply automatic reweighting to the following, beginning with the 2022 performance period:
