 In response to the impact of the ongoing COVID-19 public health emergency (PHE), we finalized a measure suppression policy in the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital (LTCH) PPS final rule for several hospital reporting programs, including the Hospital Value-Based Purchasing (VBP) Program. This policy allows us to suppress the use of measure data if the agency determines that circumstances caused by the COVID-19 PHE have affected those measures and the resulting quality scores significantly. We also finalized the suppression of 7 measures for the FY 2022 Hospital VBP Program under this policy. We believe that calculating a total performance score in the Hospital VBP Program for hospitals using only data from the remaining measures, all of which are in the Clinical Outcomes Domain, wouldn't result in a fair national comparison. Therefore, we finalized a special scoring policy for FY 2022 that won't calculate a total performance score for any hospital for FY 2022. How does this affect MIPS facility-based scoring in PY 2021? We use the total performance score from the Hospital VBP Program to calculate Merit-based Incentive Payment System (MIPS) facility-based scores for facility-based clinicians and groups in the quality and cost performance categories. The FY 2022 total performance score is what we would use to determine these scores for the 2021 MIPS performance year. - Because the FY 2022 total performance score from the Hospital VBP Program won't be available, we won't be able to calculate MIPS facility-based scoresfor the 2021 MIPS performance year.
What does this mean for MIPS reporting? Facility-based clinicians and groups will need to submit data on MIPS quality measures (except for administrative claims-based measures that have a benchmark, which are automatically calculated for clinicians and groups that meet the case minimum) to receive a score other than zero for the quality performance category. We'll automatically calculate a score for the cost performance category for facility-based clinicians and groups that meet the case minimum for at least one MIPS cost measure; there aren't any data collection or submission requirements for the cost performance category. If the facility-based clinician or group doesn't meet the case minimum for any cost measures, the cost performance category will be reweighted to 0% and the weight redistributed to other performance categories. - Facility-based clinicians and groups without available and applicable measures can request performance category reweighting by submitting an extreme and uncontrollable circumstances (EUC) application.
- Please be sure to cite "COVID-19" as the triggering event,as the decision to suppress measures in the Hospital VBP Program was in response to the COVID-19 PHE.
Additional Resources The Centers for Medicare & Medicaid Services (CMS) would like to remind you that the end of the 2022 MIPS Self-Nomination period for Qualified Clinical Data Registries (QCDRs) and Qualified Registries is September 1, 2021 at 8 p.m. Eastern Time (ET). The Self-Nomination form on the Quality Payment Program (QPP) website will lock at the deadline and additional edits will not be permitted by users. Please ensure that your 2022 MIPS Self-Nomination form is complete and click the Submit for Review button before the deadline on the QPP website. You can only submit the Self-Nomination form for review after all required fields are complete on each tab. Each tab has a vertical progress indicator on the left side of the form that shows your progress. A green checkmark shows you've completed the tab, and the Submit for Review button becomes enabled when all the required fields are completed. Once you've selected the Submit for Review button, the Entity landing page will list your Self-Nomination form with the nomination status In Self-Nomination Review. 
If you have submitted your Self-Nomination form, please check your submitted application periodically for any follow-up questions regarding your Self-Nomination form or QCDR measures, and/or correspondence as a high volume of notifications are sent. Please contact the MIPS QCDR/Registry Support Team (PIMMS Team) at QCDRVendorSupport@gdit.com or RegistryVendorSupport@gdit.com, if you cannot find your simplified Self-Nomination form instead of creating and submitting a new Self-Nomination form for your organization. Please ensure that a member of your organization has a QPP account with the appropriate associated role. Please note that sharing Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) account credentials with other users is not permitted and is considered a security violation. Each individual user must have their own HARP account to log in to QPP.cms.gov. Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties. For More Information Visit the Quality Payment Program Resource Library to download the 2022 Self-Nomination Toolkit for QCDRs & Qualified Registries and learn more about the QCDR and Qualified Registry self-nomination process. Questions? Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov, Monday-Friday 8 a.m.- 8 p.m. ET. To receive assistance more quickly, please consider calling during non-peak hours—before 10 a.m. and after 2 p.m. ET. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant. | 
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