CMS Promoting Interoperability and Merit-based Incentive Payment System

The Centers for Medicare & Medicaid Services (CMS) have revised existing public health reporting requirements for eligible professionals (EP) participating in the Merit-based Incentive Payment System (MIPS)and eligible hospitals (EH) and critical access hospitals (CAH) participating in Promoting Interoperability Program (PIP) in the calendar year (CY) 2023.

The CT DPH 2023 Project Status Letter (PIP & MIPS) is available here: 

• Program Year 2023 Promoting Interoperability Public Health Measure Update (3/31/2023)

For your reference, the 2022 Project Status Letter is here:

• Program Year 2022 Promoting Interoperability Public Health Measure Update (3/31/2022)

CMS Updates

The first CMS change in CY 2023 is that the three active engagement options have been condensed into two options:

• Option 1 Pre-production and Validation. The eligible participant has completed registration with DPH to submit data and is engaged in testing and validation or waiting for an invitation to begin testing and validation.
• Option 2 Validated Data Production. The eligible participant hospital or CAH has completed testing and validation of the electronic submission and its electronically submitting production data (clinical level data) to the PHA or CDR.
  Please see CMS 2023 Program Requirements for specific information.

If an EP/EH/CAH is already engaged with DPH programs for these public health reporting measures, they will move to one of these Options automatically. New engagements in 2023 will start with new Option 1.

The specific requirements for EPs/EHs/CAHs for public health reporting to DPH are:

• For the EPs participating in the 2023 MIPS, the regulation requires reporting of two measures associated with the Public Health and Clinical Data Exchange Objective: Immunization Registry Reporting, and Electronic Case Reporting or requesting applicable exclusion(s). An EP must be engaged or newly engage in new Option 1 to receive points.
• For the EHs and CAHs participating in the 2023 Medicare PIP, the regulation requires reporting of four of the existing Public Health and Clinical Data Exchange Objective measures: Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting, and Electronic Reportable Laboratory Result Reporting or requesting applicable exclusion(s). An EH/CAH must be engaged or newly engage in new Option 1 to receive points.

DPH Contacts

To register for submitting data to DPH, please see the link or email below:

• Electronic Case Reporting (email: ECRInformatics@ct.gov)
• Electronic Laboratory Reporting
• Immunization Data
• Syndromic Surveillance

Contact information is on the linked pages. Please follow instructions or email contacts about verification for attestation.

Exclusions

If a participant is taking an exclusion, they are not required to register with DPH. If registered, the participant is considered in active engagement Option 1 and cannot claim an exclusion. DPH is not involved in granting exclusions. To follow-up with CMS directly, see information below:

• For MIPS: Eligible clinicians may contact the Quality Payment Program help desk for assistance at qpp@cms.hhs.gov or 1-866-288-8292
• For PIP: Medicare eligible hospitals may contact the QualityNet help desk for assistance at qnetsupport@hcqis.org or 1-866-288-8912

Information for EHR Vendors and Healthcare Organizations

PIP and MIPS require the use of certified EHR technology (CERHT) that meets the 2015 Edition Health IT Certification Criteria including the 2015 Edition Cures Update for eCR implementation. Standards, implementation specifications, and certification criteria for EHR technology have been adopted by the Secretary of the Department of Health and Human Services. EHR technology must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB) for a provider to qualify for EHR incentive payments. Please use the links below to obtain more information. 

• 2015 Edition Health IT Certification Criteria
• 2015 Edition Cures Update
• ONC-Authorized Testing and Certification Bodies – the organizations listed on this website have been authorized to perform complete EHR and/or EHR Module testing and certification.

Helpful Websites and Resources:

• 2023 PIP Program Requirements
• CDC Public Health Data Interoperability webpage includes links to CMS content
• Merit-based Incentive Payment System (MIPS) Overview - QPP
• Timeline and Important Deadlines - QPP