Clinical Workflow for Successful MIPS Quality Measure Reporting
Updated 06/06/2022

How to Use This Guide

Do you participate in the Merit-Based Incentive Payment System (MIPS) of the Quality Payment Program (QPP)? If you do, please review the following page about MIPS Quality Measure Reporting for the Program Year 2022.

  • Find the measures below you plan to report on.
  • Please supply your list of measures, a contact name, and phone number in a new MICentral Support Case, referencing “MIPS Quality Measure Reporting PY2022, Health eFilings” in the Focus Area.
  • Does your current workflow reflect the steps in this guide? If not, please contact support to confirm all necessary setup is in place for your selected measures.

There are new coding requirements for Performance Year (PY) 2022, please do not assume that your setup is correct and in place from PY 2021. It is especially important that you are aware of this.

 

MEASURE DESCRIPTION DATA
22 High Blood Pressure: Lifestyle Recommendation Performed Perform Blood Pressure and record in Vitals.
 
Record Lifestyle recommendations in ORDERS. Individual orders are generated and marked as Done. The ORDERS must have a department of HBP. The Orders are found in the PLAN section and are as follows:
 
·         Weight Reduction
·         Dietary Approach to Stop Hypertension
·         Dietary Sodium Restriction
·         Increase Physical Activity
·         Moderation in Alcohol (ETOH)
 
The HBP Follow-Up Plan is also in the PLAN section and are as follows:
 
·         Follow-Up in 2-3 months for HBP
·         Follow-Up in 4-6 months for HBP
·         Referral to Another Provider for HBP
 
You may have lifestyle recommendations already in your workflow. MedInformatix can add specific Order Codes to these for documentation.
 
Order an EKG in the PLAN section and once the results are received, mark the Order as DONE. The EKG Date is recorded in the LAB area of MedInformatix with the results as the findings of the EKG (e.g., Normal, Abnormal).
50 Closing the Referral Loop Place an Order for an Outbound Referral. The Referring Provider returns a consult/report. The Order is marked Done. 
68 Documentation of Current Medications in the Medical Record Perform a Medication Reconciliation in the Medication History Screen and click the Record Reconciliation Done button. An order is generated in the background and automatically marked as done. This system order cannot be changed by the customer and is ineligible for customization.
69 Preventive Care and Screening: BMI and Follow-Up Plan  Weight and Height are recorded in Vitals which auto generates a BMI. Follow up orders are generated in the PLAN area for follow up or patient refusal within the order generated. Follow up order is marked as Done when action is met.
 
Follow up can also be for orders for a Below Normal BMI. 
 
Referrals can also be created when weight assessment may occur. In this case a referral specifically for an assessment of above or below normal BMI. Order is created. Report/Consult is received from the referral source and the order is marked as Done.
122 Diabetes: HgBA1C in Poor Control (>9.0, Normal is <6.5) Record the Hemoglobin A1C in the Lab Data Entry in MedInformatix. The Date of the test and the A1C value is entered. 
124 Last HPV Screening and/or Last PAP Screening Date and Result – Cervical Cancer Screening The last HPV and/or last PAP result is entered into Lab Data Entry. The date is the date of the test, the result is entered as Normal or Abnormal. 
125 Breast Cancer Screening – Date of Last Mammogram If a patient has had a mastectomy, record this in the problem list with the proper personal history ICD-10: Z90.11 (right breast only), Z90.12 (left breast only), Z90.13 (bilateral breasts). This permanently excludes the patient from this measure.
 
If you do not perform screening mammography but orders this service: This should be considered a diagnostic test and ordered by the provider. The order should be marked done when the diagnostic test results are received and the results of the test should be recorded in Lab Data Entry in a Screening area with a test of Mammogram, and a result of the documented BIRAD or Normal/Abnormal in the report received.
127 Pneumococcal Vaccination for Older Adults  If you administer immunizations:
Record the vaccination in the Vaccination/Immunization screen, Vaccine Hist in the Medication History Screen. They must record full immunization details. 
 
If you do not administer, but record, immunizations: 
Record the vaccination in the Vaccinations/Immunization screen, Vaccine Hist in the Medication History Screen. The Customer would use the field to show 'Out of the Office' administration status and only record the date. 
 
130 Colorectal Cancer Screening: Last Colonoscopy and/or Flexible Sigmoidoscopy Date Record a Colonoscopy or Flexible Sigmoidoscopy Date in Lab Data Entry, area of Screening. Record the Date and a result of either Positive or Negative.
131 Diabetes: Retinal/Dilated Eye Examination Record the OD and OS Periphery in the Fundus Keyview for a Dilated Eye Examination.
133 Cataracts: 20/40 or better Visual Acuity within 90 days of Cataract Surgery Enter the Visual Acuity into the VA/Refraction Screen. Each eye is recorded separately in the VA Distance, with the proper visit date associated with the examination. 
 
The BCVA (Best Corrected Visual Acuity) is recorded in Refraction Types of Manifest, Manifest(2), Corrected, Cycloplegic or BCVA After Cat Surg with a result of 20/40 or better. 
 
The Cataract Surgery Date comes from the Billing of the Cataract Surgery. Only 2 CPT codes are valid: 66984 and 66982.
138 Screening: Tobacco Use and Cessation Tobacco Screening: Enter the proper SNOMED code into Social History, GOVSMOKING
 
Tobacco Cessation: Cessation counseling is performed by creating an Education Order for Tobacco Cessation Counseling or Smoking Cessation Counseling and the order is marked as either Done or Refused.
139 Screening: Fall Risk Fall Risk Screening is entered into Lab Data Entry, area Screening, Fall Risk/more than 2 falls, with a result entry of Yes or No
142 Diabetic Retinopathy: Letter to PCP A Fundus Examination is entered into the Fundus Keyview in the areas of OD/OS Periphery and/or OD/OS Macular
 
An Order is generated as “Diabetic Retinopathy Letter” which is marked Done when the letter is sent, and the patient has diagnosis in E10.3%, E11.3% or E11.9%
143 Optic Nerve Evaluation for Primary Open Angle Glaucoma Record data in the Fundus Keyview in the OD/OS Cup to Disc Ratio and OD/OS Optic Disc
147 Preventive Care and Screening: Last Influenza Vaccination If you administer immunizations: 
Record the vaccination in the Vaccination/Immunization screen, Vaccine Hist in the Medication History Screen. They must record full immunization details. 
 
If you do not administer, but record, immunizations:
Record the vaccination in the Vaccinations/Immunization screen, Vaccine Hist in the Medication History Screen. The Customer would use the field to show 'Out of the Office' administration status and only record the date. 
156 Use of High-Risk Medications in Older Adults Medications are entered in the Medication History. This measure is defined by the medication entered and the age of the patient.