CMS Web Interface Questions Answered

Welcome to the "CMS Web InterfaceQuestions Answered" page.

Below are questions that have either been posted to the QualityNet Help Desk or asked of Cana Howard, our Lead Abstractor. If you have CMS Web Interface questions that were asked and answered and would like to share, please send them to James Malayang. As for emailing questions to Cana Howard, make sure you have the correct address: cmshims@med.umich.edu.

 

If a practice is reporting ACI through their EHR registry, do they need an EIDM account? The practice wouldn’t need to access the qpp.cms.gov, and thus no need for an EIDM account. (1/18/2018)

No answer has been received for this question.

 

Our ACO's beneficiary sample has patients with the same ranking in two different measure? These are being given in same ranking number in BMI and Tobacco?? (1/12/2018)

Hi James, It is possible and not unexpected for a given beneficiary to have the same ranking number in multiple measure. Best, Olivia

--QPP Service Center Production

 

For the PY 2017 sampled patient rank file available in the MFT, there is a column called “CEC” at the end. If a patient with a value of “Yes” in that column this patient is in the Comprehensive ESRD program, and I believe that they are supposed to be removed from the MSSP program. In our patient rank file there are 14 such patients out of the 3,578 sampled patients. Should we still abstract for these patients or not? (1/8/2018)

No answer has been received for this question.

 

Follow up question: Our institution uses “Care Everywhere” where we can view documentation from visits that patients have had with providers outside of our ACO. Using CARE-1 as an example, can we use documentation of post-discharge medication reconciliation that we can view using “Care Everywhere” if it occurred at an office outside of our ACO? Or can we only use documentation by members of our ACO? (12/18/2017)

As long as you have the required patient record information available to you at the point of care, and that information meets the requirement of the measure, you may utilize it for the web interface measures.
Please let me know if this addresses your question. I will leave this ticket open until mid-day Monday in case you need further clarification.
Thank you,
Allison
QPP PIMMS Team

--QPP Service Center Production

 

For PREV-13, what happens if the patient refuses the statin prescription and their reason is not related to adverse effect, allergy or intolerance? I don't see an exclusion reason for medication refusal so am I correct in thinking that this counts against us since there would be no prescription on the chart. (12/12/2017)

If it is documented in the medical record that the patient was prescribed statin therapy during the measurement period but refused the prescription, the intent of the measure has been met.

Thank you,
Angie Stevenson
PIMMS Measures Team

--QPP Service Center Production

Follow-up: So then is it correct to say that the provider MUST formally prescribe the statin medication in order for the ACO to receive credit for this measure? In other words, even if the provider knows ahead of time that the patient will refuse to take the medication, the provider must still go through the motions of formally prescribing the medication before the patient's refusal is considered to be disqualifying? (12/20/2017)

If it is documented in the medical record that the clinician advised the patient they wanted them to begin statin therapy and the patient stated refusal of the prescription during the measurement period, the intent of the measure has been met.

Thank you,
Angie Stevenson
PIMMS Measures Team

--QPP Service Center Production

 

For PREV-9, is the 6 month look-back calculated using the most recent BMI and NOT the most recent visit. How is the date of the most recent BMI used? (12/12/2017)

If a BMI was not documented during the most recent encounter, then you can look back through the medical records 6 months (<7 months) to see if a BMI was documented. If there is more than one BMI in that 6 month time frame then you must use the most recent BMI.

Thank you,
Jessica Schumacher
PIMMS Measures Team

--QPP Service Center Production

 

If a beneficiary has an SNP code that will exclude them from the measure, what supporting documentation would be needed to pass an audit? (12/5/2017)

You may select the Denominator Exclusion during the denominator confirmation process if medical record documentation indicates the patient is 65 or older during the measurement period and in Institutional Special Needs Plan (SNP) or resides in any of the following types of Long Term Care:

  • (POS32) Nursing Facility: A long-term facility which primarily provides residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities.
  • (POS 33) Custodial Care Facility: A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
  • (POS 34) Hospice: A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.
  • (POS 54) Intermediate Care Facility/Intellectuals with Disabilities A facility which primarily provides health-related care and services above the level of custodial care to individuals but does not provide the level of care or treatment available in a hospital or SNF.

Please note that patients in POS 31 Skilled Nursing Facility (short term) are not excluded from the measure. Also worth noting is if the patient is considered to be in hospice they should be removed at the patient confirmation level and not the measure level as this is a submission method wide requirement.

When submitting data through the CMS Web Interface, the expectation is that medical record documentation is available that supports the action reported in the Web Interface.

Thank you,
Angie Stevenson
PIMMS Measures Team

 

For the new CMS Web Interface Excel Template, will the Clinic ID and Provider Name 1, 2, 3 fields be populated when we download it with our patient sample? (11/29/2017)

The Web Interface templates are blank and only contain dummy patient data. The templates are simply examples for users to get a snapshot of how the files will look ahead of time. You can refer to the User Guide for direction as to how to complete the templates, but the templates themselves are just for show.

Once the submission period is open, you will be given new files which contain your beneficiary data. Unfortunately we don't have a date set for when your files will be available. Until then, the Web Interface Excel template is just for you to get an idea beforehand.

--QPP Service Center Production

 

Our ACO is a track 1 and for several reasons their EIDM Group and Role are different: PQRS Provider/Web Interface Submitter or PV Provider/Group Representative. Do all our abstractors have to have the same group and role? (11/27/2017)

They are not all required to have the same roles. Please refer to the EIDM User Guide for the definitions of each role available for the Quality Payment Program. You can locate the EIDM User Guide on the CMS website at https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Enterprise-Identity-Data-Management-EIDM-User-Guide.pdf

--QPP Service Center Production

 

Do you have to change your EIDM password every 45 days? (11/3/2017)

If you change your password, the new password will expire in 60 days and needs to be changed prior to expiration. This is done by logging into your EIDM account and clicking the "My Profile" tab. The URL for EIDM is portal.cms.gov

--QPP Service Center Production