PI Checklist

For the 2019 reporting year, AQI is not collecting or submitting Promoting Interoperability (PI), previously known as Advancing Care Information (ACI) data, to CMS. MIPS-eligible clinicians (ECs) who are not sure whether they qualify for an exemption from the Promoting Interoperability performance category or those who are considering participating in PI should review the following steps for deciding the best path for possible PI attestation and data submission.

Note: If practices are submitting quality and improvement activity MIPS component data as a group to AQI AND they are required to or elect to submit PI data, they must then submit that PI data as a group via a separate reporting mechanism or vendor.

STEP 1: Check your MIPS Participation Status on the Quality Payment Program (QPP) website.
Enter your 10-digit National Provider Identifier (NPI) number in the QPP site to determine whether you are exempt from MIPS. 

STEP 2: Check your Certified Electronic Health Record Technology (CEHRT) to determine that you have the correct edition required.
First, make plans to acquire, verify or update Certified Electronic Health Record Technology (CEHRT) to the 2015 edition. The Office of the National Coordinator for Health Information Technology (ONC) has developed a comprehensive database of certified EHR technology where ECs can check their CEHRT.

STEP 3: Determine whether you are a hospital-based MIPS eligible clinician.
CMS defines a hospital-based clinician as a MIPS-eligible clinician who furnishes 75% or more of his or her covered professional services in POS 19 (off-campus outpatient hospital), POS 21 (inpatient hospital), POS 22 (on-campus outpatient hospital), or POS 23 (emergency room).

ECs can check their status on the QPP MIPS Participation Status website. Hospital-based MIPS ECs will have their PI category automatically reweighted to zero and those points shifted to the Quality component. Please note, those hospital-based ECs that wish to participate despite having the exemption may submit PI data and will receive a PI score even if they were not required to submit data. 

STEP 4: Determine whether you are a non-patient facing MIPS-eligible clinician.

ECs can check their status on the QPP MIPS Participation Status website. Non-patient facing MIPS ECs will have their PI category automatically reweighted to zero and those points shifted to the Quality component. Please note, those non-patient facing ECs that wish to participate despite having the exemption may submit PI data and will receive an PI score if they were not required to submit data.

STEP 5: Determine whether you have other “Special Status” exceptions.

There is also an exception for Ambulatory Surgery Center-based eligible clinicians. CMS defines this as a MIPS eligible clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by POS 24. ECs can check their status on the QPP MIPS Participation Status website.

STEP 6: Determine whether you qualify for additional exemptions and apply using the CMS Hardship Application

There are three additional exemptions from PI that require submission of a CMS Hardship Application:

  1. Insufficient Internet Connection: (Practicing in an area without sufficient internet access or facing insurmountable barriers to obtaining infrastructure, such as a lack of broadband access)
  2. Extreme and Uncontrollable Circumstance: (Natural disasters, practice or hospital closure, severe financial distress, EHR certification/vendor issues)
  3. Lack of Control over the Availability of CEHRT: (Inability to control CEHRT availability in more than 50 percent of patient encounters)

Additionally, ECs can apply for a Small Practice exception, which exempts eligible clinicians who are part of a practice with 15 or fewer clinicians. For the 2019 performance year, these hardship applications are due on December 31, 2019. If CMS grants one of these hardships, ECs will have their PI category reweighted to zero and those points shifted to the Quality component.

Those ECs who have an exemption from PI in 2019 and do not wish to participate need not review Steps 7-10.

STEP 7: If you are participating in PI, pick a performance period of at least 90 days.
ECs participating in PI must attest to and submit at least 90 days of 2019 data to CMS. This must be a continuous 90-day period. 

STEP 8: Review the PI Scoring Requirements and determine which score components are most applicable to you and your practice.

In order to secure full credit towards the 25% weight of the MIPS Promoting Interoperability (PI) performance category, MIPS eligible clinicians must report on four different objectives consisting of a total of five measures for the 2019 performance year. There are two bonus point opportunities worth 5 points each for the 2019 performance year. The maximum number of points an EC can receive in 2019 is 110 points. Please note, however, that the score is capped at 100 percent.

The measures will be scored, depending on the measure, on the EC’s performance through the submission of a numerator or denominator or a “yes or no” attestation.

STEP 9: Choose your submission methods and verify their capabilities.
ECs who are reporting as individuals can submit measures via multiple collection types:

1. MIPS CQM
2. eCQM
3. QCDR measures
4. For small practices, Medicare Part B claims measures

Groups, including virtual groups can submit measures via multiple collection types:

1. MIPS CQM
2. eCQM
3. QCDR measures
4. CMS Web Interface (for large practices)
5. Medicare Part B claims measures (for small practices)

Please note, for both individual and group submission, if the same measure is submitted via multiple collection types, the one with the greatest number of points will be used in scoring. However, CMS Web Interface measures cannot be scored with other collection types other than CMS approved survey vendor measure for CAHPS for MIPS and/or other administrative claims measures.

For more information on Group Reporting versus Individual Reporting, QCDR and QR Reporting Requirements and other relevant considerations, please see the ASA MIPS Reporting – NACOR Page.

STEP 10: Submit your PI data by March 31, 2020.

More PI Information

You can also find CMS Resources here and ASA FAQs here for all things MACRA.