June 2019
Promoting Interoperability (PI) Category
2019 PI Objectives and Measures
Promoting Interoperability Measure Specifications
Promoting Interoperability Prevention of Information Blocking Attestation
Quality Web Interface Measures
MIPS CATEGORIES
For practices participating in the 2019 GPAC Medicare Shared Savings Program, you will be scored based on the MIPS APM scoring as indicated below:
Quality- 50%
Eligible clinicians in the GPAC ACO get a quality performance score based on the CMS Web Interface and CAHPS for ACO quality measures that are reported by the ACO.
The CMS Web Interface Measures can be found by clicking on the link:
Promoting Interoperability-30%
Eligible clinicians in the GPAC ACO report at the group or individual level.
Data is aggregated and weighted to get a single GPAC ACO score that applies to all eligible clinicians in the GPAC ACO.
The PI measures can be found by clicking on the link:
Improvement Activities-20%
Eligible clinicians in the ACO get full credit based on ACO participation.
No additional reporting is necessary.
Cost-0%
N/A under the APM Scoring Standard.
Low Volume Threshold (LVT)
Determined at the ACO level. This means that even if clinicians or groups are at or below the low volume threshold of $90,000 in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS), furnishing 200 or fewer covered professional services to Medicare Part B beneficiaries, or furnishing covered professional services to 200 or fewer Medicare Part B beneficiaries, if they bill through the TIN of an ACO participant or if the group is an ACO participant, they will be subject to MIPS if the ACO exceeds the low volume threshold. It is rare that an ACO does not exceed the low volume threshold.
QPP Link
CMS QUALITY PAYMENT PROGRAM (QPP) WEBSITE LINK:
You must have access to the QPP website to submit your PI data for 2019. Please start the enrollment process now.
Promoting Interoperability Performance Category
Basics for 2019
30% of your MIPS APM Final Score
To earn a score for the Promoting Interoperability performance category, you must:
-Use 2015 Edition CEHRT for the performance period (90-days or greater)
-Submit a “yes” to the Prevention of Information Blocking Attestation
-Submit a “yes” to the ONC Direct Review Attestation
-Submit a “yes” for the Security Risk Analysis measure
-Report the required measures under each objective
Four Objectives:
1. e-Prescribing
2. Health Information Exchange
3. Provider to Patient Exchange
4. Public Health and Clinical Data Exchange
Minimum performance period of any continuous 90-day period within the calendar year
2019 PI Objectives and Measures
Objectives |
Measures |
|
e-Prescribing |
• e-Prescribing |
|
• Bonus: Query of Prescription Drug Monitoring Program (PDMP) (new) |
|
|
• Bonus: Verify Opioid Treatment Agreement (new) |
|
|
Health Information Exchange |
• Support Electronic Referral Loops by Sending Health Information (formerly Send a Summary of Care) |
|
• Support Electronic Referral Loops by Receiving and Incorporating Health Information (new) |
|
|
Provider to Patient Exchange |
• Provide Patients Electronic Access to their Health Information (formerly Provide Patient Access) |
|
Public Health and Clinical Data Exchange |
• Immunization Registry Reporting |
|
• Electronic Case Reporting |
|
|
• Public Health Registry Reporting |
|
|
• Clinical Data Registry Reporting |
|
|
• Syndromic Surveillance Reporting |
2019 Promoting Interoperability Measure Specifications
More about 2015 Edition CEHRT
• 2015 Edition functionality must be in place by the first day of the Promoting Interoperability performance period
• Product must be certified to the 2015 Edition criteria by the last day of the Promoting Interoperability performance period
• Must use the 2015 Edition functionality for the full Promoting Interoperability performance period
Not sure what Edition your EHR is?
Search for your EHR product(s) on the Certified Health IT Product List (CHPL) website, https://chpl.healthit.gov/#/search
OR ask your EMR vendor
Submitting PI
•All MIPS eligible clinicians will report data for the PI performance category under the general MIPS requirements.
•PI can be reported via attestation, QCDR, Qualified Registry, CEHRT, or the CMS Web Interface.
•MIPS eligible clinicians in any MIPS APMs, including the Shared Savings Program, can report PI in any manner permissible under MIPS (i.e., at either the individual or group level).
The Merit-based Incentive Payment System (MIPS) Promoting Interoperability Prevention of Information Blocking Attestation: Making Sure EHR Information is Shared
Quality
Web Interface Measures collected and submitted by GPAC
- Falls: Screening for Future Fall Risk
- Composite (All or Nothing Scoring): Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
- Controlling High Blood Pressure
- Depression Remission at Twelve Months
- Breast Cancer Screening
- Colorectal Cancer Screening
- Preventive Care and Screening: Influenza Immunization
- Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
CAHPS Survey Organized by GPAC
2019 CAHPS Survey Measures
- Getting Timely Care, Appointments, and Information
- How Well Providers Communicate
- Patient’s Rating of Provider
- Access to Specialists
- Health Promotion and Education
- Shared Decision Making
- Health Status and Functional Status
- Courteous and Helpful Office Staff
- Care Coordination
- Stewardship of Patient Resources
Claims Based Measures collected via claim submitted
Quality Claims Based Measures
- Risk-Standardized, All Condition Readmission
- All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
- Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91)
2019 CMS Web Interface Measures and Specifications
Please visit your EMR website to obtain more educational materials regarding dashboards and users guides.
IMPORTANT INFORMATION TO NOTE
Public Health and Clinical Data Exchange EXCLUSIONS
Each of the five measures has their own exclusions; please refer to the Measure Specifications Sheets for the exact exclusion criteria for each measure. Generally speaking, the exclusions are based on the following criteria:
1. Does not diagnose or directly treat any disease or condition associated with a agency/registry in their jurisdiction during the performance period.
2. Operates in a jurisdiction for which no agency/registry is capable of accepting electronic registry transactions in the specific
standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no agency/registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.
Low Volume Threshold (LVT)
Determined at the ACO level. This means that even if clinicians or groups are at or below the low volume threshold of $90,000 in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS), furnishing 200 or fewer covered professional services to Medicare Part B beneficiaries, or furnishing covered professional services to 200 or fewer Medicare Part B beneficiaries, if they bill through the TIN of an ACO participant or if the group is an ACO participant, they will be subject to MIPS if the ACO exceeds the low volume threshold. It is rare that an ACO does not exceed the low volume threshold.
Security Risk Analysis
The security risk analysis may be conducted outside the MIPS performance period, but it must be conducted for the CEHRT used during the MIPS performance period.
The analysis or review must be conducted on an annual basis and within the calendar year of the performance period.
QPP Registration and Access
You must have access to the QPP website to submit your PI data for 2019. Please start the enrollment process now.
2015 Edition CEHRT
- 2015 Edition functionality must be in place by the first day of the Promoting Interoperability performance period
- Product must be certified to the 2015 Edition criteria by the last day of the Promoting Interoperability performance period
- Must use the 2015 Edition functionality for the full Promoting Interoperability performance period
- Please visit the Certified Health IT Product List (CHPL) site at : https://chpl.healthit.gov/#/search to search your EMR edition or enter your EMR version CHPL # to confirm 2015 Edition.
March 29, 2017
Attention all MSSP Members,
Please review the below information and tools from CMS on Medicare Revalidation.
The Shared Savings Program requires all ACO participants to be enrolled in Medicare (42 CFR § 425.20). Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled ACO providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening requirements. In order to streamline the revalidation process and reduce the ACO providers/suppliers burden, CMS implemented several revalidation processing improvements. We believe these tools are helpful for reminding your ACO providers/suppliers to revalidate timely and maintain their Medicare enrollment in order to minimize any adverse impact to their ACO participant status. The most efficient way for a provider or supplier to submit revalidation information is by using the Internet-based Provider Enrollment Chain and Ownership System (PECOS) on the CMS website https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 . PECOS allows you to review information currently on file, update, and submit a revalidation via the Internet.
It is important for providers and suppliers to keep all of their contact information in PECOS up-to-date so the Medicare Administrative Contractor (MAC) can contact them as needed. A listing of all currently enrolled providers/suppliers is available by using the Medicare Revalidation List https://data.cms.gov/revalidation . You can search for a provider/supplier by last name, first name, organization name, or by National Provider Identifier (NPI),or download a list of revalidation due dates. Those on the list due for revalidation will display a revalidation due date, all other providers/suppliers not up for revalidation will display a “TBD” (to be determined) in the due date field.
The revalidation due date will be posted up to six months in advance of the revalidation due date to provide sufficient notice and time for the ACO provider/supplier to comply. The revalidation due date list is refreshed once every two months on or around the first of the month and two months of due dates are appended at that time. For more information on ACO provider/supplier revalidation, please visit the CMS Revalidation webpage https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/revalidations.html or have the provider/supplier contact their MAC.
December 15, 2016
Did your practice receive and review annual compliance training? If you did not or you have any questions please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it.
August 19, 2016
Join us Monday, August 22, from 6-7pm ET for a complimentary webinar with Evolent Health’s policy expert and GPAC’s leaders that explains:
- What MIPS is
- How MIPS impacts you
- How you can meet the MIPS requirements
- The GPAC advantage for you as a provider
For those of you who are unable to join live, this important webinar will be recorded and made available to all GPAC physicians, practice managers and staff to watch at a later date.
Presenters
Steve Barry
Chief Executive Officer
Georgia Physicians for Accountable Care
Chris Dawe
Principle, Transformation
Evolent Health
Cindy Lenderman
Director, Physician Services
Georgia Physicians for Accountable Care
Lisa Shah
Senior Vice President of Practice Optimization
Evolent Health
REGISTER HERE!
July 15,2016
GPAC is now enrolling new members to join GPAC. If you know any providers or practices who would like further information about GPAC or would like to join please contact Jessica Thompson at (478) 345-8056 or This email address is being protected from spambots. You need JavaScript enabled to view it..
June 10, 2016
2016 MSSP Participants ONLY
When GPAC satisfactorily reports the GPRO Quality Measures and Administers the CAHPS Survey for 2016, ALL providers that bill under an approved 2016 GPAC participant TIN will:
AUTOMATICALLY-Avoid the 2018 PQRS negative payment adjustment (-2.0%)
OPTIONAL-Satisfy the CQM component of the Medicare EHR Incentive Program(during the MU Attestation you will notify CMS if you chose to have the ACO quality measures also satisfy your MU CQM's)
NOTE-EP's will still be required to report the other MU objectives through the MU registration and Attestation system.
AUTOMATICALLY-The 2018 Value Modifier adjustment will be determined by the data submitted by GPAC and will vary by the composition and size of the participant TIN.
If you have any questions please contact Cindy Lenderman at 478-345-8061.
June 3, 2016
Are all of your providers enrolled in PECOS under your TIN? If you are not sure please take a moment to check at this link:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
As always, if we can assist you or answer any questions please call GPAC at (478)345-8056.
May 6,2016
Did you receive your GPAC Town Hall invitation? Please contact Jessica Thompson (478) 447-4812 or This email address is being protected from spambots. You need JavaScript enabled to view it. for an invitation or to RSVP to this event.
April 28,2016
Providers and Office Adm/Managers,
GPAC will be hosting a Town Hall Meeting on May 12th at 6:00 PM to make an exciting announcement that is going to change the face of HealthCare in Georgia!
While the event will be broadcast on the web across the state, with the opportunity for bi-directional communication, we’d love to see you at the Town Hall Meeting. Please make plans to attend.
Additional details to follow.
April 15, 2016
Georgia Physicians for Accountable care is now enrolling new members. If you know someone who would like to join GPAC or obtain additional information about this exciting opportunity, please ask them to contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. or (478)345-8056 ASAP.
April 8, 2016
Annual Well Visits- Please ensure all your Medicare patients receive their annual wellness check-up. This appointment is valuable to the overall management of care to your patient. Please contact Noah Hanover at (478)345-8057 for additional information.
April 1, 2016
Physician Action Dashboard-Please check your Physician Action Dashboard on a periodic basis. This dashboard has vital information to help you manage and care for your patients. Please contact Noah Hanover at (478)345-8057 for additional information.
March 25, 2016
Medicare Shared Savings Program Participants (MSSP)-
The GPAC Medicare Shared Savings program (MSSP) requires 34 quality measures to be reported for 2016. As a participant of the GPAC MSSP you need to be aware of all the measures and be advised on how to meet the 18 quality measures that will be collected from your EMR for data submission. Please note that this data submission will satisfy your PQRS requirement for 2016, fulfill your Value Modifier and can also satisfy your the CQM portion of the EHR Meaningful Use attestation.
United Health Care Participants
The GPAC United Healthcare Shared Savings program requires 12 quality measures to be reported for 2016. As a participant of the GPAC UHC shared savings program you need to be aware of all the measures and be advised on how to meet the 10 quality measures that will be collected from your EMR for data submission.
We are wrapping up the 2016 GPAC Quality Measure training. Has your practice been trained? If you need to reschedule or are unsure if your practice has completed the training please contact Jessica Thompson at (478) 345-8056 or This email address is being protected from spambots. You need JavaScript enabled to view it. IMMEDIATELY.
March 11, 2016
2015 ACO Quality Measure reporting is wrapping up. The mandatory training on the 2016 MSSP and/or United Quality Measures has begun. Jessica Thompson will be reaching out to you to schedule your training soon.
March 4, 2016
"Whether in the waiting room or the exam room, ContextMedia:Health provides services in the form of digital media to promote lifestyle information ranging from healthier cooking and eating tips to improving chronic condition management. Digital media is displayed on multiple devices including a Flat-Panel TV, Interactive Digital Wallboard, and Samsung Galaxy4 Tablets - all provided to your practice free-of-charge. Please take some time to view the GPAC Presentation from ContextMedia:Health to learn more about our partnership and how your practice can benefit." Please contact Noah Hanover at (478) 345-8057 for additional information.
February 19, 2016
Is your practice providing Chronic Care Management services? GPAC is able to assist our providers with providing these services. Please call (478) 345-8056 or email Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. for more information.
Has your practice opted in to the United Healthcare commercial shared savings? Contact Jessica Thompson at (478) 345-8056 or This email address is being protected from spambots. You need JavaScript enabled to view it. for more information.
January 22, 2016
It is the 2015 ACO Quality Measure data collection time. Please note that when the ACO submits the ACO Quality measures this will satisfy the providers 2015 PQRS requirement. We look forward to working with you to complete this important and time sensitive task. Please let us know if you have any questions.
December 29, 2015
Have you see the new Your Doctors Immediate Care website? http://yourdoctorsimmediatecare.com/
December 18, 2015
2015 MSSP PARTICIPANTS ONLY
In early Jan. 2016 GPAC will receive the sample list of Medicare Recipients that we will need to collect and submit the ACO Quality Measure data to CMS. Please note that the submission of this data will satisfy your PQRS and Value Modifier requirement for 2015.
December 11,2015
Please see the below contact list for GPAC staff.
|
Employee Name |
|
Office Phone Number |
Title |
|
Steve Barry |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
(478) 345-8059 |
C. E. O. |
|
Cindy Lenderman |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
(478) 345-8061 |
Director of Physician Services |
|
Jennifer Thomas |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
Physician Service Specialist |
|
|
Jessica Thompson |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
(478) 345-8056 |
Executive Assistant |
|
Melanie Black |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
(478) 832-8616 |
Manager of Your Doctor's Immediate Care |
|
Noah Hanover |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
(478) 345-8057 |
Physician Services Coordinator |
|
Cherie Holliman |
This email address is being protected from spambots. You need JavaScript enabled to view it. |
(478) 239-4164 |
Care Coach |
November 20, 2015
Have you heard the great news?
******YOUR DOCTORS IMMEDIATE CARE in MACON is NOW OPEN******
Be sure to share the news with your patients.
Visit their website at http://yourdoctorsimmediatecare.com/ for more information.
November 3, 2015
October 30, 2015
We are very excited to announce the opening of Your Doctor Immediate Care in Macon at 2410 Ingleside Avenue Macon, GA 31204. The doors will be open for business on Monday, November 2, 2015. The hours of operation are as follows:
• Monday - Friday: 9am to 9pm
• Saturday: 10am to 7pm
• Sunday: 11am to 7pm
Your Doctors Immediate Care is also located in Gray at 260 W Clinton Street Gray, GA 31032. The hours of operation for the Gray location are as follows:
• Monday - Thursday: 5pm to 10pm
• Friday: 2pm to 10pm
• Saturday: 10am to 5pm
• Sundays : 11am to 5pm
If you would like to know more about the Your Doctors Immediate Care services please contact Melanie Black at This email address is being protected from spambots. You need JavaScript enabled to view it. or (478) 832-8616.
October 23, 2015
ATTENTION:
EFFECTIVE NOVEMBER 1, 2015-There is a new GPAC Medicare Beneficiary Notice, Poster and Process. Please see the email sent from Jessica Thompson on 10/19/2015 for details. If you have questions or did not receive please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it.
October 16, 2015
Attention Providers: Have you received your invitation to the open house for Your Doctors Immediate Care in Macon? If you did not receive your invitation and would like to attend please contact Jessica Thompson at (478) 447-4812 or This email address is being protected from spambots. You need JavaScript enabled to view it.
October 9, 2015
Have you sent in your GPAC Capability Audit? Please contact Jessica Thompson at (478) 447-4812 or This email address is being protected from spambots. You need JavaScript enabled to view it. if you have any questions.
October 2, 2015
Please join GPAC in welcoming Noah Hanover to our team. Noah has accepted the role of Physician Services Coordinator at GPAC. Noah graduated from Mercer University with a B.A. in History and a minor in Biology. Noah is originally from Memphis, Tennessee, enjoys golf and is an avid sports fan. Noah will be working extensively with the Physician Action Dashboards. Noah will ensure that all practices are able to access the dashboards, are educated on the dashboards and understand the actions that must be taken on the dashboards. Noah can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. or (478) 345-8057.
September 25, 2015
Has your practice completed training on the GPAC Physician Specific Action Dashboard? If not, please contact Jessica Thompson at (478) 447- 4812 or This email address is being protected from spambots. You need JavaScript enabled to view it. to schedule an appointment.
September 18, 2015
Are you receiving the Action Committee Alerts? They are being sent from This email address is being protected from spambots. You need JavaScript enabled to view it. Please contact Jessica Thompson at (478) 447-4812 or This email address is being protected from spambots. You need JavaScript enabled to view it. if you have any questions.
September 11, 2015
Are you accessing the provider dashboard at https://caweb.eclinicalweb.com/portal/auth ? Please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. or (478) 447-4812 for additional information
September 4, 2015
Please see the below ICD 10 information:
ICD-10 Clinical Concepts For Family Practice:
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsFamilyPractice1.pdf
ICD-10 Clinical Concepts for Cardiology
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsCardiology1.pdf
ICD-10 Clinical Concepts for OB GYN
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsOBGYN1.pdf
ICD-10 Clinical Concepts for Internal Medicine
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsInternalMedicine1.pdf
ICD-10 Clinical Concepts for Orthopedics
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsOrthopedics1.pdf
August 28, 2015
Physician Action Dashboard
2015 MSSP Providers and Office managers should have received their dashboard user name and temporary passcode. This information would have been sent From: This email address is being protected from spambots. You need JavaScript enabled to view it., If you have not received the email with your user name and temporary passcode please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it.
August 21, 2015
GPAC Membership
Please share the news that physicians can join GPAC at anytime; however, the deadline to participate in the 2016 Medicare Shared Savings Plan with GPAC is September 8, 2015. Please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. for additional information.
GPAC Newsletter
Are we you receiving the GPAC Newsletters, if not, please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. ?
Physician Action Dashboard
GPAC will be setting up access for physicians and office managers to view the Physician Action Dashboard over the next few days. The Physician Action Dashboard is expected to be available by August 28, 2015.
August 14, 2015
Please help us in welcoming the following new GPAC practices. If you know of anyone who would like additional information about GPAC please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it.
Atlanta ENT, Sinus and Allergy Associates, P.C.
Burton Medical Group, LLC
Charles B Shiver, III M.D.
Convenient Care LLC
Dawsonville Family Medicine
InStitches, PC
John Wesley King Jr. M.D.
Marion Family Medicine, PC
Maya Hosein, MD
Meyer Cardiology, PC
Olena Klindukhova, MD
Physicians MRI Inc
Russell Minor
Sandra H. Gibbs, M.D.
Southeastern center for infectious diesase, PA
Southern Medical Clinic, LLC
Sylvanus Fiakpornoo
The Shaw Center for Womens's Health, PC
William L Waller III MD
Your Doctors Immediate Care
August 7, 2015
Have you heard... Your Doctors Immediate Care will be opening soon in two locations to serve you Macon, GA and Gray, GA. If you would like further information about these locations. Please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. .
July, 31, 2015
Do you have friends or colleagues who would like further information on GPAC? Please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it.
July 24, 2015
We will begin our pilot Telehealth program soon. If your practice would like more information on participation please contact Jessica Thompson at This email address is being protected from spambots. You need JavaScript enabled to view it. . Did your practice receive this months Annual Wellness Visit list?
July 17, 2015
Is your practice doing Chronic Care Management? Let GPAC assist you to provide this service to your patients. Contact Amanda Hood at This email address is being protected from spambots. You need JavaScript enabled to view it. for more information. Did your practice receive the GPAC newsletter this week?
July 10, 2015
Let GPAC assist you using the Provista discounts program with Office Max, Verizon (up to 22%) and Best Buy discounts! You can even use the Verizon discount as an added benefit to your employees. The preferred pricing discounts offered may reduce your overhead cost and the discounts for employees provide additional benefits for employees at no cost to you. Please email Jessica Thompson for more information This email address is being protected from spambots. You need JavaScript enabled to view it.
June 26, 2015
GPAC is kicking off a Gold Card Program for your patients!! Call Amanda Hood at 478-239-4164 to learn more.