CMS Announces Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19

The Centers for Medicare & Medicaid Services (CMS) is supporting clinicians on the front lines by getting red tape out of the way so the healthcare delivery system can focus on the 2019 Novel Coronavirus (COVID-19) response. CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming quality measure reporting and data submission deadlines for the following CMS programs:

Provider Programs	2019 Data Submission	2020 Data Submission
Quality Payment Program – Merit-based Incentive Payment System (MIPS)	Deadline extended from March 31, 2020 to April 30, 2020. MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.	CMS is evaluating options for providing relief around participation and data submission for 2020.
Medicare Shared Savings Program Accountable Care Organizations (ACOs)

Hospital Programs	2019 Data Submission	2020 Data Submission
Ambulatory Surgical Center Quality Reporting Program	Deadlines for October 1, 2019 – December 31, 2019 (Q4) data submission optional. If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate). If data for Q4 is unable to be submitted, the 2019 performance will be calculated based on data from January 1, 2019 – September 30, 2019 (Q1-Q3) and available data.	CMS will not count data from January 1, 2020 through June 30, 2020 (Q1-Q2) for performance or payment programs. Data does not need to be submitted to CMS for this time period. * For the Hospital-Acquired Condition Reduction Program and the Hospital Value-Based Purchasing Program, if data from January 1, 2020 – March 31, 2020 (Q1) is submitted, it will be used for scoring in the program (where appropriate).
CrownWeb National ESRD Patient Registry and Quality Measure Reporting System
End-Stage Renal Disease (ESRD) Quality Incentive Program
Hospital-Acquired Condition Reduction Program
Hospital Inpatient Quality Reporting Program
Hospital Outpatient Quality Reporting Program
Hospital Readmissions Reduction Program
Hospital Value-Based Purchasing Program
Inpatient Psychiatric Facility Quality Reporting Program
PPS-Exempt Cancer Hospital Quality Reporting Program
Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals

Post-Acute Care (PAC) Programs	2019 Data Submission	2020 Data Submission
Home Health Quality Reporting Program	Deadlines for October 1, 2019 – December 31, 2019 (Q4) data submission optional. If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate).	Data from January 1, 2020 through June 30, 2020 (Q1-Q2) does not need to be submitted to CMS for purposes of complying with quality reporting program requirements. * Home Health and Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from January 1, 2020 through September 30, 2020 (Q1-Q3) does not need to be submitted to CMS. For the Skilled Nursing Facility (SNF) Value-Based Purchasing Program*, qualifying claims will be excluded from the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510) calculation for Q1-Q2.
Hospice Quality Reporting Program
Inpatient Rehabilitation Facility Quality Reporting Program
Long Term Care Hospital Quality Reporting Program
Skilled Nursing Facility Quality Reporting Program
Skilled Nursing Facility Value-Based Purchasing Program

CMS is granting exceptions and extensions to assist health care providers and suppliers while they direct their resources toward caring for their patients and ensuring the health and safety of patients and staff. For those programs with data submission deadlines in April and May 2020, submission of those data will be optional based on the facility’s choice to report. In addition, no data reflecting services provided January 1, 2020-June 30, 2020 will be used in CMS’ calculations for the Medicare quality reporting and value-based purchasing programs in order to reduce providers’ data collection and reporting burden as they are responding to the COVID-19 pandemic.

CMS recognizes that quality measure reporting may not be reflective of performance for measures such as cost, readmissions and patient experience during this time of emergency and seeks to hold organizations harmless for data during this period. CMS will continue to monitor the situation and adjust reporting periods and submission deadlines accordingly. More detailed information about changes to each of these quality reporting programs will be provided soon.

2019 MIPS Submission Deadline Extended: Submit 2019 Data by April 30, 2020

The 2019 Merit-based Incentive Payment System (MIPS) data submission deadline will be extended by 30 days to April 30, 2020. If you have already submitted MIPS data or if you submit MIPS data by April 30, 2020, you will be scored and receive a MIPS payment adjustment based on the data you submit. Many MIPS eligible clinicians have performed very well in the MIPS program in previous years. If you need to revise any data that has already been submitted you can still make changes by logging into qpp.cms.gov by the new deadline.

2019 MIPS Automatic Extreme and Uncontrollable Circumstances Policy Update

MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 do not need to take any additional action to qualify for the automatic extreme and uncontrollable circumstances policy. These clinicians will be automatically identified and receive a neutral payment adjustment for the 2021 MIPS payment year. All four MIPS performance categories for these clinicians will be weighted at zero percent, resulting in a score equal to the performance threshold, and a neutral MIPS payment adjustment for the 2021 MIPS payment year. However, if a MIPS eligible clinician submits data on two or more MIPS performance categories, they will be scored and receive a 2021 MIPS payment adjustment based on their 2019 MIPS final score.

CMS will continue monitoring the developing COVID-19 situation and assess options to bring additional relief to clinicians and their staff so they can focus on caring for patients.

For More Information

Please reference the 2019 QPP Data Submission User Guide. CMS also has up to date information about its programs and response to COVID-19 on the Current Emergencies page.

For Quality Payment Program questions you can contact 1-866-288-8292, Monday through Friday, 8:00 AM-8:00 PM ET or by e-mail at: QPP@cms.hhs.gov.