MIPS 2023: Quick Start Guide

Keet joined the WebPT family at the start of 2022 to help us advance our overarching mission: to empower rehab therapists to achieve greatness in practice. In line with this mission is our combined aim to help our Members excel in value-based care. As such, we are transitioning our MIPS solution to Keet—a CMS-approved QCDR—starting January 1, 2023.

With Keet, you’ll have everything you need to succeed in MIPS without adding administrative stress on yourself or your team. Key features include:

• Automated patient surveys: Automatically send patient questionnaires and MIPS patient reported outcome measures from the Keet platform to free up your staff from handing out surveys.
• Enhanced data collection: Increase the cadence of questionnaire delivery to improve your number of completed surveys funneled into reporting.
• Performance Benchmarks: Benchmark your performance against a large pool of organization and national averages to easily view where your practice stands. 
• Intuitive MIPS compliance tools: Simply input your outcomes and let Keet handle the provisioning, scoring, risk-adjusting and reporting throughout the year to support a seamless submission process.

Let's get started: 

MIPS Setup

Before you can begin collecting MIPS data, there are a few setup steps to complete.

Choose Reporting Method and Verify Employer Identification Number (EIN)

The first step of completing MIPS Setup in the WebPT EMR is to choose how you’ll be submitting your data—as a group or individually—and to verify the Employer Identification Number (EIN) for each clinic location participating in MIPS.

Upon logging in to the WebPT EMR, you’ll be greeted by a popup requesting that you complete MIPS Setup. Click MIPS Setup in the Tools section of the Dashboard to visit the MIPS Setup Page.

Individual vs Group Reporting

If a MIPS-eligible clinician decides to report as an individual (the default option), they will be evaluated and scored based on their performance only. The individual will be the only clinician to receive a payment adjustment based on their unique score.  

If a MIPS-eligible clinician elects to report as a group along with one or more other clinicians who bill under the same Tax Identification Number (TIN), CMS will evaluate and score the group’s performance as a whole. Every member of the group will receive the same adjustment based on the group’s overall score. 

Keep in mind that MIPS eligibility is determined on an individual basis, which means that a group will never be required to participate. However, if clinicians choose to participate as a group, then all  MIPS eligible clinicians at that clinic are required to participate and will receive the same score and payment adjustment.

Click here to learn more about the pros and cons of reporting as an individual or group. 

If the providers in your practice are reporting as a group, select the group checkbox. If they are reporting individually, no action is needed. 

Verify that the EIN displayed is correct. Remember, the EIN can also be referred to as the TIN. If the number is not correct, simply type the correct number into the box. Click Verify and Select Measures.

Click Save. 

Provider Setup

The next step of MIPS setup is to apply the appropriate permission to the participating providers.

Individual Reporting

1. Open User Manager.                                                                
2. On the User Manager page, select the MIPS checkbox for each provider you are enrolling in Registry reporting.
3. You’ll receive a warning dialog box, letting you know that you must enroll each provider at a Company level. While the provider is auto-enrolled for each clinic in your organization, if your organization has two companies, and you have providers that work in both, they’ll need to be enrolled from the User Manager page for each company.
4. Alternatively, if you are enrolling all eligible providers in your company, select the Enable/Disable All button.                                                   
5. In the dialog box that opens, you’ll need to confirm your choice by selecting Enable All.
6. Using this option does not allow you to report as a group.

Group Reporting

Because your organization has decided to enroll as a group (by selecting the Group checkbox above), all eligible providers will automatically be enrolled in MIPS and will have a “Group” designation in the MIPS column of the User Manager.

No additional steps are needed.

Keet Setup

After the WebPT EMR setup is complete, the MIPS Administrator designated when you purchased Keet MIPS will have a few setup steps within the Keet platform. 

First, they’ll receive an email with the subject “ Join Your Team!”. This email contains the instructions for how to create their Keet login credentials. Once this email is received, it is valid for three days. 

After they can log in to Keet, they’ll need to invite team members. Care Team members will be visible in Keet already, but they’ll need this invitation to register their accounts. After their accounts are registered, they’ll be able to access Keet directly from the WebPT EMR through the MIPS badge on the patient chart! Learn how to invite Care Team Members to Keet.

The last piece of setup in Keet is to enable Automated Global Workflows. Global Workflows are a combination of emails, exercises, questionnaires, and/or education articles that you set to be delivered to patients under circumstances called "triggers". While this step is optional, we strongly recommend completing it to ensure all patients receive the right PRO at the right time. Learn how to enable Keet Global Workflows. 

There are 2 Global Workflows you’ll want to enable:

1. The Auto Invite Global Workflow
   • This sends an email with information about Keet and how patients can register for and access the Keet platform to complete their assigned PROs.
2. The MIPS Global Workflow
   • This will automatically assign a Qualification survey to a patient once their Initial Evaluation has been scheduled. Based on the patient’s responses in the Qualification survey, the workflow will assign the appropriate PRO to the patient’s Care Plan. The PRO will be assigned to the patient’s Care Plan immediately after the Qualification survey is completed. This workflow will also assign the same PRO to the Care Plan 21 and 42 days after the Qualification survey was completed.
     • Clinicians can manually assign the PRO at desired intervals as well.

Quality Measures

MIPS participants must submit data  on a minimum of six Quality Measures. If you collect data for more than six measures, your best six will be sent. Choosing to collect data for more than six measures gives you more options to ensure that you’ve scored as many points as you can for the Quality Measures category. Learn more about the Quality Measures available. 

Documenting Quality Measures

Quality Measures data will be primarily collected through Keet, with supporting documentation captured inside notes in WebPT EMR. Here’s a high level overview of the workflow:

Step 1: Evaluate Patients for MIPS Eligibility

The first step of MIPS reporting is to determine which patients are eligible for MIPS reporting. Generally speaking, patients are not eligible for MIPS reporting if they meet any of the following criteria: 

• Under the age of 18
• Non-English speaking and translation services are unavailable
• Unable to accurately complete the MIPS PRO due to a mental or cognitive impairment
• Meet Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15
• Are determined to be extremely medical complex and likely to make poor clinical progress based on the experience and clinical judgment of the treating clinician
• Ongoing care is not indicated

If a patient is not eligible for MIPS reporting, they must be marked as disqualified in Keet. Click here to learn how to disqualify patients from MIPS in Keet. 

Patients who are not disqualified from MIPS will receive a survey. This survey is a qualification survey to determine the body part for which the patient is seeking treatment. Then, a Patient Reported Outcome (PRO) questionnaire is sent to the patient before their Initial Evaluation to determine the patient’s perceived severity of the condition. Each PRO corresponds to a MIPS Quality Measure.

If a patient does not complete prior to the IE, they can complete the PROs at the clinic using a unique QR code, with an ipad/kiosk, or with the clinician at the time of eval. To best leverage Keet, we highly recommend training your front desk staff on educating the patient of the importance of filling out the PROs ahead of time when scheduling their initial evaluation. This will free up clerical and clinical time by automating outcomes collection. Click here to learn more.

Step 2: Document the Initial Evaluation in the WebPT EMR

At the time of the patient’s Initial Evaluation, clinicians will document in the note as they normally do. Any fields associated with MIPS reporting are marked with a MIPS tag. 

Subjective Tab

Objective Tab

Before finalizing the note, clinicians access the Keet platform by clicking the MIPS badge on the patient’s chart, where they will be prompted to log into Keet and document all MIPS measure data.

Step 3: Document the MIPS data in Keet

In Keet, clinicians will then add activities to the patient’s care plan that correspond with the MIPS measure data collected in the WebPT EMR. The data entered into Keet will be collated and submitted to CMS during the MIPS submission period. The data in the WebPT EMR supports what you submit to CMS in the event of an audit.

Learn how to add activities to a Care Plan in Keet.

Step 4: Finalize the note

Once everything is documented appropriately, return to the WebPT EMR and finalize the note. 

Step 5: Follow-up visits

Patients will be automatically sent their PRO follow-up questionnaire periodically throughout their care if Keet’s Global Workflows are enabled. PRO’s must be completed by the patient at least twice during their care to calculate the change score and apply the risk adjustment formula required to determine the patient’s MCID. 

Learn how to enable global workflows in Keet.

Improvement Activities

Improvement Activities are classified as either “medium” or “high” depending on the demands of the activity, and they award 10 and 20 points, respectively. You may report any relevant activity from any subcategory, but you must submit activities with one of the following combinations of weighting: 

• Two high-weighted activities,
• One high-weighted activity and two medium-weighted activities, or
• Four medium-weighted activities.

To successfully complete the Improvement Activities category, individual MIPS participants must perform each of their chosen activities for a consecutive 90-day period at some point during the performance year. At least 50% of the NPIs that report as a group must complete these activities in order for the full group to receive credit.

There are some exceptions to the weighting of Improvement Activities for:

• clinicians who work in a small practice,
• non-patient facing clinicians, and/or
• clinicians who are located in rural areas or Health Professional Shortage Areas (HPSAs).

In these cases, medium-weighted activities are worth 20 points, and high-weighted activities are worth 40 points.

Download the Improvement Activities Quick Start Guide provided by CMS, or learn about some Improvement Activities popular among rehab therapy practices. 

Documenting Improvement Activities

There are 2 ways WebPT Members can attest to Improvement Activities:

• Sign in to qpp.cms.gov and attest to (manually select) the activities you’ve performed.
• Sign in to qpp.cms.gov and upload a file with your activity attestations.

The Improvement Activity Submission deadline for the 2023 Performance Year is March 31, 2024. 

Coming Soon

In the works are some reporting features so that you can monitor your MIPS and patient outcomes data throughout the year. Stay tuned!