Web Interface Support Webinar

December 13, 2017

Full List of Q&A
Question Questioner First Name Questioner Last Name Questioner Email Answer Respondent
The data to be populated to Excel will now be Yes or No N/A N/A
instead of 1 or 2, am I correct?
Adam Tham adam.tham@memorialhermann.org
Will the excel be accepting Yes or No value instead of 1 or 2? N/A N/A

Just confirming the Data Guidance sheets ar enot sepreate this That is correct. The data guidance information is Debra
year, they are included in the narrative specifications now included in the measure documents and Kaldenberg
identified as Submission Guidance. The measure
calculation flows are also included in the measure
Alicia Rebello rebelloa@southcoast.org documents. Thanks

How do we get a copy of all Q&A from this call? N/A N/A
The 'MSSP Quality Measure Benchmarks for the 2016 and ACO-44 is in the quality measure set for 2017 for Olivia Berzin
2017 Reporting Years' document indicates that Imaging for ACOs, but it will be calculated using Medicare
Low Back Pain is a measure for 2017, but it has not been claims data and is not collected via the CMS Web
covered in the recent reporting webinars. Can you confirm if Alyssa Endres alyssa.endres@bswhealth.org Interface.
this measure is included for 2017 or not?

Do we need to upload via excel? or can we manually enter into N/A N/A
the WI like we have been in past?
Amanda Panteliodis apanteliodis@pbaco.org
Do we NEED to upload via excel or can we manually enter into You may manually enter data into the CMS Web Olivia Berzin
the WI? Interface if you prefer.
In the Excel template, fields are not listed for the ACO TIN (fka N/A N/A
group TIN). We have multiple ACOs that we will be loading to a
data warehouse. Will that field be included in the download?

We have a sofrware application that we havfe built internally. N/A N/A

Last year we exported an XML file with the defined numeric Amy Allred amy.allred@chessmso.com
answers and CMS tags from our database. This year if we
export an Excel file with the appropriate Excel headers and
alpha text answers, will this work when we drop the Excel file
in the uploader or must it be the formated Excel template?

Will there be a training on the ACI submission? Angela Wininger angela.wininger@ulp.org N/A N/A
For the IVD measure if the member meets the measure You would exclude the patient during the Angela
because is on Aspirin but also takes an anticoagulant would we Denominator Confirmation process as shown on Stevenson
include in the measure or would we exclude the member. Annmarie Starret annmarie.starret@lowellgeneral.org Page 7 of the measure specifications.

Can we still receive end to end reporting bonus points if we N/A N/A
upload some data using excel and manually add data later on Areeba Ali armali@utmb.edu
via the portal?

On the portal under our EIDM login each time I try to N/A N/A
"register" our ACO under the CMS Enterprise Portal >
Quality Payment Program > CMS Web Interface / CAHPS for
MIPS Survey area however it keeps stating Registration not
available at this time for this TIN. Is there anything additional Bianca Blankenship bblankenship@iefmc.org
that needs to be done once our roles are setup in EIDM??

In the past years reporting for PQRS, we've uploaded data XML will not be supported. The Excel Template Ralph
using XML format. Does an organization have to use the Excel must be used. Trautwein
template or is there an XML option for upload?

The Frequently Asked Questions document provided in Bonnie Norris norris.bonnie@mayo.edu N/A N/A
previous years for abstraction was quite helpful. I did not see
this document on the website yet. Is there a document
available yet? If not, will there be, and when?

The excel spreadsheet supmission seems tailored to ACOs that The excel spreadsheet may be programatically Ralph
perform manual abstraction rather than automated data pulls populated. For example, the CMS Web Interface, Trautwein
from the EHR. .Are there any plans to accept XML files for programattically pupulates the spreadsheet when
submission from those ACOs who have the technology preparing a download. XML will not be supported.
support?
Brad Miller brmiller@lghealth.org
What date will the requirements (much like the XML specs N/A N/A
from last year) be available?
are we able to copy and paste SQL results into the Excel N/A N/A
template?
Will CMS hold a similar webinar that walks trhough ACI N/A N/A
reporting? Brandon Danz bdanz@wellspan.org

I haven't heard anyone mention the XML upload option. Is XML is not support. The Excel format is used for Ralph
XML upload still supported? Brian Garraty brian.garraty@tpmgpc.com bulk reporting. Trautwein
Where can I obtain a copy of the FAQ? N/A N/A
This may be a silly question. Does all supporting N/A N/A
documentation need to come from the outpatient record
only?
Cana Howard cmshims@med.umich.edu
1. Can we abstract "live" data during the training session, N/A N/A
download our data, and the reupload the data once the site
goes "live"?

Hi. Group reporting. I'm not sure if I missed this information N/A N/A
but I wonder if Excel submission is the only way to report
data? Or is the option to individually report available? Carlos Rosado rosadoc@einstein.edu

On the Excel template, I noticed there were multiple columns N/A N/A
for the CMS Ticket, is this a mistake or is this intended?

My last question was regarding for Prev- 13. N/A N/A

Carmen Penna cpenna@itsguardian.com
In the XLS template for PREV-13 there are multiple columns for N/A N/A
QPP Service Center Ticket Number. Is this a mistake in the XLS
file are is there 3 separate ticket entries needed?

I do not yet see today's slides posted on the portal. When can N/A N/A
we expect them? Carole Romano cromano@prohealthcare.com

Will the ranked sample provided on January 8th be in the The sample will be populated into the excel Ralph
format of the excel template or in xml format as in previous template. XML will not be provided. To retrieve Trautwein
years? Where do we get it? your sample you will need to sign in to QPP and
download your sample from the CMS Web
Interface.

Basically, my question is, is the ranked sample provided Yes, it will be in the same format except it will no Sarah Grallert
through MFT going to be in the same format as last year? longer include visit dates that were necessary for
Thank you. the CARE 3 measure (as that measure has been
retired this year).

Caroline Wise caroline@healthendeavors.com

Every once in a while a patient could be out of age for a Caroline Wise caroline@healthendeavors.com Yes, you are able to edit these data manually Sarah Grallert
measure. Can we update a patient's date of birth manually in within the WI.
the web interface as before or how should this be handled?

The excel template does not include dates for the office visit in N/A N/A
Care-1 measures. This value is no longer required?

Regarding Care 1 dates, the excel template has space for only N/A N/A
10 discharge dates so that would effectively limit how many
dates there are per patient, right?

2 step verification will be based on eidm selected preference N/A N/A

correct? Cecile Favreau crf2y@virginia.edu

Can you discuss how ACI submission through the web interface N/A N/A
will work?
How do you recommend organization ensure their data is N/A N/A
secured during the upload process? Can the WI handle
encrypted files or upload from a secure filepath?

The Excel Template continues to be updated. At what point will CMS reserves the ability to make corrections to Ralph
the formatting be finalized? Chela Gans chela@epic.com the template as needed. Please be aware that the Trautwein
template has had updates based on testing and
feedback.

If a patient does not meet the age/gender requirements, what N/A N/A
should be upload in the Excel file? I understand that we can
manually correct the DOB/Sex in the Web Interface, but what's
an appropriate return for the Excel file's upload?

can you please post the youtube links? Christina Tomaselli tochrist@montefiore.org N/A N/A
Will we get a more fully populated Excel beneficiary sample N/A N/A
file prior to the live files on January 8?
Will TINS also be included? I had received a response from N/A N/A
QPP stating that neither TINS nor NPIS would be included.

Also, will there be a new Excel template provided? The current N/A N/A
template doesn't have a place for the NPIs (or TINs if they are
to be included).

Will we get a fully populated sample Excel prior to the January ACOs will receive an MFT transfer of the Sarah Grallert
8 delivery of the real data? beneficiary ranking files on January 8th. Providers
will also be able to download their beneficiary
Chuck Kandzierski chuck.kandzierski@clinigence.com data at that time.

Future EIDM enhancement request: It would be great if we N/A N/A

could request more than one role at a time. We work with 12
ACOs and have to wait until the requested roled is approved
before we can move onto the next ACO role request.

Will TINs be provided in the downloaded sample? Top TINS are not available in the downloadable Sarah Grallert
excel, but will be available in the WI itself.

Can we use the Excel spreadsheet to answer Care 1 questions? N/A N/A
If so, how would we do that?
Does CMS recognize the Z codes for BMI? Corinna Suiter corinnas345@gmail.com N/A N/A
For ACO - Can we upload excel's by TIN's or do we have to N/A N/A
submit one excel for the Entire ACO - to include all TIN's that
belong to that ACO?

For Post Discharge Medication Reconciliation Measaure, will The discharge dates will be prefilled and the dates Debra
the dates be pre-filled? Or we do only measure providers on must be confirmed +/-2 calendar days of the Kaldenberg
the hospital D/C notes, we find in the specific patients medical prefilled date. Thanks
record?

Will claims data for the FLU vaccines, be available in the N/A N/A
downloadable excel, just like it was pre-filled in the WI last Cristina Sarria cristina@aco-fl.com
year? If they had a claim for the FLu Vaccine admin, the WI
would be pre-filled with a YES.

For the Ischemic Vascular Disease Measure (IVD) - how will we N/A N/A
know which diagnosis codes will be considered as an Active
Ischemic Vascular disease for the current measurement year?
Or is it limited to a: CABG, MI & PCI for both previous and
current measurement year?

Will we be able to submit XML files to CMS for this year, or do XML is not supported in the CMS Web Interface Ralph
we have to use the Excel format? for this reporting Period. The excel format may be Trautwein
used for bulk reporting. The CMS Web Interface
David White white.david@mayo.edu also allows for manual input.

Can we do a combination of data entry in the web interface N/A N/A

and upload using the Excel file to get the bonus point per Debbie Nypaver nypaverd@summahealth.org
measure?

We keep losing voic on the internet and we do not have a dial N/A N/A
in number with our registration Debra Reakes dreakes@coastalmedical.com

The CMS Proposed Rules included changes to two measures - N/A N/A
BMI plan of care - once in CY vs 6 mos and the Tobacco
Assessment and Cessation Intervention - 1 rate to 3 rates. Debra Barnhart debra.barnhart@mercy.net
Were these measure changes finalized?

Please describe the consecutive patient model. Dee Dee Seagraves seagravesd@sjchs.org N/A N/A
How will the CMS pre-populated data for the influenza N/A N/A
measure be downloaded? As well as the medication
reconciliation discharge dates?

Can we separate the excel spreadsheet into individual N/A N/A

measures and upload them separately as long as we upload
the demographic information, the patient confirmation
information and all of the measure required columns?

Denice Duus denice.duus@unitypoint.org

PREV9 BMI ; this year the 65 and older BMI range was N/A N/A
removed, but 65 and older can now qualify as an exception if
underlying health conditions exist. I do not find any specific
diagnosis codes for the health conditions listed. Are we to use
our best judgement to consider a patient an exception or do
we need to submit a ticket to CMS for a CMS approved reason
for excepting a patient?

I just want to make sure we have appopriate access. can you N/A N/A
provide me the link to where we would upload or download Desiree Rivera drivera@montefiore.org
our data and retrieve our sample?
Med Rec Measure: our EMR automaitcally populates d/c meds N/A N/A
from hospital and autipopulate to meds list when patient
comes to the practice. What is exactly needed in the
medication list in the office in the event of an audit what will Diana Amedy diana.amedy@carolinashealthcare.org
we need to produce?

What about ACI and Web Interface? N/A N/A

If I change something that should not have changed - such as N/A N/A
the Medicare ID - (Check for Errors in Step 9) Will I need to find
the information and fix it, or is that changed row simply Dick Daswick rdaswick@mercydesmoines.org
rejected?

As a web submiter would I upload my information periodically N/A N/A

or is the data in the excel sheet automatically uploaded per Donna Mimikos donna.mimikos@beaumont.org
CMS at regular intervals.

For a MSSP Track 1, at the beginning of your slides, at the main N/A N/A
page after signing in, rather than clicking on MIPS Groups
should we click on APMs? That was not clear. Dru White druwhite@gmail.com

as a PCMH we are atesting to our status to get credit for the N/A N/A
exemption for Improvement Activity category. Woud we still
need to report Quality data on the web interface?. Ed Kerner edward.kerner@urbanhealthplan.org

How quickly the errors in the uploaded excell file are Errors are found real time during the upload and Ralph
detected? Elena Sukharsky elena.sukharsky@spencepartners.net published at the conclusion of the upload in the Trautwein
CMS Web Interface.

Could you confirm the third diagnosis listed on slide 45? I N/A N/A
thought I read screening for hypertension. Should that slide Elizabeth Savaria-Porter esavariaporter@neqca.org
read Controlling for High Blood Pressure?

There are only 14 measures listed in bullet one - is the 15th The measure count of 15 includes counting both Debra
measure Care 1? of the diabetes measures in the DM composite. Kaldenberg
Thanks

Is there a 2017 Q&A document posted somewhere as we are N/A N/A

used to seeing historically?
Are these frequently asked questions getting posted in a N/A N/A
formal Q&A document to reference as they have in past years?

Emily Wilfong emily.wilfong@phci.org

Like the other callers, we also generate a portion of our N/A N/A
submission data programmatically following the defined
numerology used in prior years. Changing the process away
from numerology to entirely new submission values is an
unexpected additional effort. Why did removing the extra step
of generating an xml formated file also need to include
changing all of the values themselves, too?

Regarding CARE-1, would the Medical Assistant or LVN be able
to reconcile medications via phone or in person, as long as the
appropriate practitioner type reviews and signs off?
Erica
Yes, medication reconciliation post discharge may Angela
be completed during a telehealth encounter as Stevenson
long as it is within 30 days following an inpatient
facility discharge, and that the physician,
prescribing practitioner, registered nurse, or
clinical pharmacist providing on-going care
reviewed the discharge medications from the
inpatient facility. Please see the numerator
guidance on page 9 of the measure specification
for information about telehealth encounters. Also,
Johnson erica.johnson3@memorialhermann.org be sure the medical record documentation meets
one of the criteria that defines Medical
Reconciliation listed on page 5 of the measure
specification.

For data we want to intentionally leave blank, is it N/A N/A

recommened to leave blank or use "N/A"
For care 1, the excel template has 10 discharge dates. Can we Erica Nobles nobleer1@memorialhealth.com N/A N/A
expect that no more than 10 discharge dates per patient will
be provided in the patient sample?

For the bonus point, how will points be handled if a N/A N/A
combination of upload via EXCEL and manual entry is used? Erin Rivera erin.rivera@cerner.com

when will 2018 WI quality measures be released by CMS? The Shared Savings Program did not propose or Olivia Berzin
finalize retiring measures in the 2018 PFS
rulemaking process. The PY2017 measure set is
Hanna Park hanna.park@chessmso.com the same for PY2018.

just want to clarify that 2018 MSSP ACO measures will be as N/A N/A
the 2017 ACO measures?
If I had all needed access to enter/submit data from the Web N/A N/A
Interface in 2017, I will not need to change anything in 2018,
correct?

Did I understand correctly last week that the sample patient Heather Keller hkeller@gshvin.org Yes, the beneficiary sample you receive during the Ralph
list will be the same as our actual patient list? test period will be the same beneficiary list you Trautwein
receive during the submission period.

Will a user for a TIN that is part of an ACO need to take a N/A N/A
specific action to indicate they are part of an ACO on the
QPP/MIPS screen, or will QPP/MIPS know which NPIs/TINs are
part of ACOs already?

Can a beneficiary self-report for the breast cancer, colon The posted 2017 measures documents include Debra
cancer measures and have it count as long as it is documented Heidi Harting hharting@jfkhealth.org patient reported guidance. For example on page 8 Kaldenberg
the beneficiary provided information? Or does there need to of the 2017 PREV-5 measure the following
be the official report in th chart to count for the numerator, information is included:Patient Reported
and self-reporting does not count? Requirement: Date and type of test AND
result/finding. Thanks

Can I please have the web address? N/A N/A

Can you publish the web interface website information please? htps://www.cms.gov/Medicare/Quality-Payment- Ralph
Ilea Mattison imattison@mhealth.com Program/Resource-Library/Resource-library.html Trautwein

Can you please clarify the meaning of reporting on 248 N/A N/A
"consecutive beneficiaries" for each measure. Does this mean
the 248 patients must be from a block or 248 ranked patients
with no patients skipped? (e.g 1 - 248 or 368 - 616) or do you
just need to enter data for any 248 of the 616 patients?
James Walkling walklinj@advisory.com

Can you please confirm that the discharge dates for the Care 1 N/A N/A
module will be pre-populated in the blank excel document
that is downloaded?
when logging in it references receiving the access code by text N/A N/A
message, can email be used to receive this access code?

Please clarify if the access code must be received by cell phone N/A N/A
text message. Can the access code be received by email? Jan Simonson simonson.janice@marshfieldclinic.org

Previously you had scheduled down time dates, will there be N/A N/A
scheduled down time in this audit period?
Can you please clarify the requirements around falls A falls screen completed and documented during Debra
screening? The narrative specifications state that the screening the measurement period is acceptable. The Kaldenberg
can be done within the measurement period, but based on a Denominator Exception - Non-ambulatory is tied
recent webinar it was stated that the falls screening needs to to the most recent visit. Denominator Exception,
be done at the most recent visit. count as non-ambulatory only if non-ambulatory
at the most recent encounter during the
measurement period. Thanks
Jessica Han jeh9112@nyp.org

Do you know when the 2018 narrative specs will be available Please stay tuned to the ACO Spotlight newsleter Olivia Berzin
for ACOs? and the Next Generation ACO Newsleter for an
announcement!

Will we see the sign on January 8th? I currently don't see a QPP does not have the login enabled at this time. Kenneth
sign on for the QPP site as see in the user demonstration. Please verify your Login at portal.cms.gov. Then Howard
verify roles using the My Access selection.

Will the sample list available January 8th be the same list on N/A N/A
January 22nd?
It was stated that you get a point for each measure using the Jodie Quatrocchi jodie.quatrocchi@mercy-chicago.org N/A N/A
excel upload. Will you still get a point if you also do some
manual entry.

Do you need to download the beneficiary sample on or after N/A N/A

January 22nd?. In other words we can technically start
gathering data January 8th and upload after January 22nd?

Where do we find the web address of the Web Interface? N/A N/A
Johanna Sheehey-Jones johanna.sheehey-jones@uvmhealth.org
What is the "Bonus Point" option for not using the WI? N/A N/A
Is it possible to programatically load the Excel template with N/A N/A
the data required and are there specifications for this?

I am not trying to upload an xml file. I want to know if it is N/A N/A

programatically possible to load the Excel template and were
the specifications for that would be located.

John Dines dinesj@uw.edu

We do not have the man power to manually abstract the data N/A N/A
needed for the WI filing. Is it possible for us to programatically
load the Excel Template and then uplad that? Are there
specefications for this process?

I am currently a Web Interface submiter for multiple TIN's. If N/A N/A

this is not possible then many are going to have a problem.

In the past, we could submit/load one measure at a time. Is N/A N/A

this still possible? Joy Jacobsen jjacobsen@kumc.edu

Just to be clear, there will no longer be a "Submit" buton in N/A N/A

the WI for final submission of each measure? Julia Boggs julia.boggs@arcadiasolutions.com

For Virtual Groups in 2018 reporting, will the Virtual Group N/A N/A
also receive a predetermined population of patients like ACO &
MIPS Group?

Is data entry offline only as being shown? How can we avoid N/A N/A
multiple submiters to NOT work on the same patient at the
same time?

For 2018 Virtual Groups, will Virtual Groups also receive a N/A N/A
predetermined list of benes? I know this is out of scope for this Julie Kim julie.kim@mwmc.com
webnar but no one from QPP seem to know and it makes a
signifcant operational impact. Deadline for Virtual Group sign
up is in 17 days.

FYI, for the last caller's question, we were submiters for N/A N/A
multiple ACOs last year. We were allowed to toggle between
ACO organizations in the web interface. Pls let us know if this
changed

I do not see any submissionspecification as it was released in N/A N/A

2016, the link for which is mentioned
belowhtps://qnpapp.qualitynet.org/cs/pqrs/documents/gpro/
GPROXMLSpec2016/index.htmAre we expecting something Jyoti Moryani jyoti.moryani@citiustech.com
similar for 2017 as well?

are these slides available in the resource library you were just N/A N/A
discussing? Karen LaBarge klabarge@acooklahoma.net

I am unable to locate "login" sign on the QPP webiste? Is this N/A N/A
functionality hidden at this time?
Karishma Mann karishma.mann@nm.org
Will something similar to XML spec will be made available for N/A N/A
excel spreadsheet?
If a patient has IVD and is on both coumadin and an asprin, do This would be considered a Denominator Debra
we exclude them or include them? Exclusion if the patient was taking coumadin any Kaldenberg
Kathryn Fernandez kkennedy@northwell.edu time during the measurement period. Thanks

is the beneficiary list format expected to change this year? The only difference is that this year will not Sarah Grallert
Katie Yu katie.yu@koanhealth.com include visit dates for CARE 3 since this measure
has been retired.

Will a breast thermography qualify for mammogram for the No, a breast themography is not a mammogram. Angela
Breast cancer screening for a woman with breast implants? Please refer to the PREV Coding Document, Stevenson
NumeratorCodes tab for screenings included.

Kelly Bitonio kelly.bitonio@dignityhealth.org

For Care-1, if there are a several post discharge office visits N/A N/A
within the 30 days from discharge, do you have to use the first
visit to satisfy the measure or can it be done at any of the visits
in that post 30 days?

Should we be testing our access now? QPP does not have the login enabled at this time. Kenneth
Please verify your Login at portal.cms.gov. Then Howard
verify roles using the My Access selection.

Providers have not been able to access data before? What Providers will have access to the Web Interface to Sarah Grallert
does this mean "Providers will also be able to download their download their beneficiary samples on January
beneficiary data at that time." 8th. ACOs will also receive an MFT transfer of their
beneficiary rankings.

Kris Elliot kelliot@npoinc.org

ACOs will also be able to download all sample files or will they They will be able to download their sample files as Sarah Grallert
only be available via MFT? Thank you. well as receiving them via MFT.
 Kris Elliot kelliot@npoinc.org

Will we have the same reporting features from the web The CMS Web Interface has been completely Ralph
interface that an ACO had available last year? redesigned for this reporting year. Trautwein

Do uploaded excel files populate the CMS Web INterface? Uploaded Excel files will be processed real time, Ozlem Tasel
and the data uploaded via Excel upload will
populate the CMS Web Interface.

We are an ACO with multiple TINs so we have many users Yes, You may provide the rows associated with Ralph
working on this submission. We need to seperate the data to beneficiaries that you want directed to specific Trautwein
protect PHI. Can we submit a partial excel spreadsheet, data reporter as a subset of the sample you
meaning list with patial patients? Kristen Brasslet kbrasslet@emhs.org download.

For CARE-1- does the patient have to come in for a visit if their N/A N/A
med rec was completed via phone by a registered nurse within
the 30 day period?

For PREV-13- does coronary arteriosclerosis count for the Please review the coding provided in the posted Debra
denominator? 2017 PREV Coding document. The coding is Kaldenberg
considered to be all inclusive for the purposes of
Krystyna Sienkiewicz sienkiewiczk@ihn.org mapping to an EHR. Thanks

When will the frequently asked questions document be N/A N/A

released?
For PREV-13- I see coronary atherosclerosis on the coding N/A N/A
document- is this the same thing as coronary arteriosclerosis?

I use the VIP Access from Symantec for two step verification. Is N/A N/A
this still an acceptable method for two step authentication, or
must an email or cell phone be used? Kyle Hall khall@caravanhealth.com

when will the audit measures be announced? Lacey Watles lwatles@rmhn.org N/A N/A
To follow up on the NPI question - will you be providing the Yes the excel will include the NPIs and names. Amy Mills
actual NPI, or just the names
If a user previously imports values/dates for value/date fields, qpp.cms.gov, however the signin feature has not Ralph
how will the user "null" these fields through the excel upload yet been released. Trautwein
-- the excel does not allow "N/A" in these fields (restrictions
are set to only allow dates, or numeric values in these fields) ?

When will a new template be released that has a field for the The template may be released with change. Ralph
NPI value. The 12/1 template only identifies a field for provider However, the NPI for each physician is not planned Trautwein
name to be included in the excel download.

In reviewing the template was updated12/8. It does not N/A N/A

include NPI in provider field nor a field for NPI. Only First
Name, Last Name Laura Gerety laura@lumiata.com

Olivia, thank you. To be clear - the version of excel delivered There will be additional columns. Sarah Grallert
through MFT is going to be different from the version
downloaded from the web interface. The MFT version will
contain names and NPIs. Will this be in the same field, or will it
have additional columns?

Sarah, thank you.Can you advise what additional columns (in N/A N/A
addition to 3 columns for the provider 1-3 NPIs) will be in the
MFT version of excel?

Sarah, in response to "Top TINs are not available in the N/A N/A
downloadable excel" - please clarify what will be in the clinicID
field from the downloadable excel, and excel from the MFT

for the excel template - do we have to use the template we N/A N/A
download - or can we upload any excel file as long as it is in
the format as your spreadsheet (same columns)? Laura Williams laura.williams@unchealth.unc.edu

The MFT version was just stated to be "largely like what was N/A N/A
received last year". Does this mean it will be in XML format, or Laura Gerety laura@lumiata.com
excel?

If we programmatically populate the Excel file, we should use N/A N/A

the answer options that are in the drop-downs, right? For
example, "Yes", "No" (as opposed to 2 and 1 in the XML format Lauri Scharf lscharf@bistatepca.org
last year).

Will we be able to see the appropriate drop down responses N/A N/A
for each measure prior to the testing period? The current
template example does not show the drop down responses. Leenete Guay leenete.guay@thedacare.org

Will actual sample be available on Jan 8? Yes, the sample will be available for download on Sarah Grallert
Jan 8.
Will the real sample be available within the new template N/A N/A
format or will we need to merge the template with a different
sample file? Thank you.
Leslie Alabi lc47@duke.edu
Regarding MH-1 update, the 11/15/17 version of specs N/A N/A
indicate "less than 5" for remission - are these not up to date?

On January 8, will the downloadable template (in WI) contain N/A N/A
the same information as the MFT file?
Is there a separate process to download the intial patient The download offers two types of downloads. The Ralph
sample for patient confirmation? first is a download of the original sample without Trautwein
any change. The second is a download of the
Linda Drummond linda.drummond@uwmf.wisc.edu sample with data reported to date.

Can you please clarify if an ACO is eligible for the bonus if the N/A N/A
majority of the data is uploaded via the excel document, but
last minute data changes are made manually within the WI? Lindsay Weeman lindsay.weeman@aultman.com

I have a question about ACO 20 Breast Cancer Screening. A
recent update to our Medical Group's EMR has included some
new fields for gender - current gender and born as gender.
When it comes to Breast Cancer Screening, have
accomodations been made for patients who were not born
female but are now reporting as female? We assume they
should not be included in the denominator, but may be
accidently included if just current gender is what is considered. Lindsey
We have no examples of this that we have come across, but I
wanted to verify before I spoke to our vendor about what data
to pull for reporting.
If there is a question on whether or not a patient Debra
should be considered denominator eligible based Kaldenberg
on gender for PREV-5 it would be best to ask
during submission when details can be provided. It
may be necessary to request CMS Approved
Reason to skip. CMS will review and provide a
response based on the details provided. Thanks
Freeman
lindsey.freeman@hshs.org

Will there be a toggle between data entry for multiple TINs N/A N/A
that an organization is submitting?
will we be able to download the discharge dates for CARE 1, as N/A N/A
we are reporting for multiple entities and resources do not Lisa Aker lisa.b.aker@healthpartners.com
allow to manually go in and search for those?
with such a short amount of time for data submission we We understand the concern and maintenance Ralph
request that you limit the amount of time that the WI is outages will be kept at a minimum. Trautwein
unavailable due to maintenance during the submission period. Lori Johnson johnsonlj@health.missouri.edu
Thank you

Can you please 1) re-confirm that CMS will not be issuing N/A N/A
Quick Reference Guides for the 15 PY2017 WI measures and 2)
tell us whether CMS plans to issue a CMS WI Q&A
Summary for PY2017. Thank you. Lynne Rothney-Kozlak pklrk@hotmail.com

Do the bonus points referenced on the CMS WI Demo video N/A N/A
apply to ACOs??
When will the QPP sign on buton be enabled? Mallika Hegde mallika.hegde@aurora.org N/A N/A
So, if we have mult people reporting can each person N/A N/A
download the excel spreedsheet and work their specific
measures then upload the excel multiple times? Margaret Ivory margaret.ivory@caromonthealth.org

can you provide a sample or template for the provider and N/A N/A
clinic excel files? Mark Raffensberger mraffensberger@wellspan.org

Is there a limit to the number of individuals who can serve in N/A N/A
this quality reporting role? Mark Kirschbaum mkirschbau@mauryregional.com

There is an issue with the ESRD "assginment" in 3Q2017 Hi Mary, Would you mind submitting this question Olivia Berzin
QASSIGN. Will this error carry thorugh for the web interface to SharedSavingsProgram@cms.hhs.gov so that
assigned beneficiaries? we can look into this for you?

In this webinar slide # 28 it indicated the beneficiary for web Hi Mary, Would you please submit this question to Olivia Berzin
interface will come from 3Q2017 assignable (QASSIGN). There Mary Tun tunm@dvaco.org SharedSavingsProgram@cms.hhs.gov? Thanks!
is an issue with ESRD members from CMS regarding assignable
patients in 3Q2017, will this be fixed and the beneficiary that
does not belong to the ACO will not be part of the web
interface patient list?

Will the .XML be implemented at a later date or will reporting N/A N/A
continue to be excel or direct data entry? Maureen Clarke macgroup100@gmail.com

We have an EIDM account to do our quality reporting for the
ACO. However for ACI webinterface reporting - will we be able
to use the same EIDM account for reporting of ACI per each
TIN?
Megan
If you are a Shared Savings Program ACO, Rabia Khan
participant TINs will need to report ACI to MIPS, in
the form and manner specified by MIPS.
Participant TINs will need to create EIDM accounts
and roles, similar to other group practices
Woosley megan.woosley@owensborohealth.org reporting ACI, to be able to report ACI in the QPP
Portal. QPP will be providing more information
about ACI in the coming weeks.

Are you providing quick reference guides to measures as you The contents of the Web Interface Quick Amy Mills
did last year? Reference Guides were included in the Quality
Measure Specifications for 2017:
htps://qpp.cms.gov/docs/QPP_quality_measure_
specifications.zip
Melanie Romero melanie.romero@genesishcc.com
When are you going to publish information for any retired The Shared Savings Program did not propose or Rabia Khan
2018 MSSP meaures? finalize retiring measures in the 2018 PFS
rulemaking process. The PY2017 measure set is
the same for PY2018.

How many people can work in the excel spreadsheet at a time
from different workstations? Our organization typically splits
the reporting between a few people to help even out the
workload.
Melissa
You may divide up the work in the spreadsheet Ralph
across the resources on your team. However, Trautwein
please be aware that the CMS Web Interface
enforces that only one upload per organization
can take place at a time. So, if one of your
Griffith mgriffith@wtmedical.com resources is uploading a file the others will be
prevented from uploading until the current upload
is completed.

what if we never documented any phq9 data for our patients N/A N/A
until March of 2017, when we initiated a project to start doing
this? We will have zero patients that will qualify for an 11-
month follow up of an initial phq9

ACO-42 - is does "mixed hyperlipidemia" qualify for No hyperlipidmia is not a denominator eligible Debra
denominator inclusion? diagnosis for Risk Category 2: Patients aged ≥ 21 Kaldenberg
years at the beginning of the measurement period
who have ever had a fasting or directlaboratory
result of LDL-C ≥ 190 mg/dL or were previously
Michael Seemuller michael.seemuller@anmedhealth.org diagnosed with or currently have an active
diagnosis of familial or pure hypercholesterolemia.
Thanks

If a patient has an existing diagnois of depression for years, N/A N/A

and they do not have an index phq9, or if their index phq9
score was more than 2 years ago, what do we count as the
index phq9 score?

Are there any scenarios where after we upload the Excel N/A N/A
template we can only update the record via a manual on-line Michael Anderson michael-anderson-4@uiowa.edu
edit?

will any other measure pre-populate with claims data like the N/A N/A
flu measure (for instance, diabetic eye exams or Michael Seemuller michael.seemuller@anmedhealth.org
mammograms)?

What is considered qualified professionals? N/A N/A

Does active medication include prescription at an ED visit? N/A N/A
Michell Poyaoan mpoyaoan@memorialcare.org

What is considered qualified professionals? N/A N/A

When you upload the Excel spreadsheet multiple times does it N/A N/A
override the previously submited data? Michelle Robinson mrobinson@mpgus.com

Hi, in the past for the two-step logon authentication, the code N/A N/A
was able to be emailed to us instead of via text message. Is
email route available this year as well or only text message? Michelle Lucarelli michelle.lucarelli@advocatehealth.com

Will CMS be providing NPIs via the excel spreadsheet this Yes NPIs will be provided in the excel spreadsheet. Amy Mills
year? Nandini Ramananda ramanandan@dvaco.org

Can an ACO submit patients at a measure level or does the N/A N/A
ACO have to submit all abstrations for a patient?
Nandini Ramananda ramanandan@dvaco.org
Thank you, will there still be upto 3 NPIs per patient listed? Yes, each patient will be associated with up to Olivia Berzin
Same as last year? three NPIs, same as in previous years.
Will the NPIs in the MFT delivered patient sample be included The Provider Names will be provided in separate Sarah Grallert
with the provider name or will it just be the NPI? If the names columns from the Provider NPIs.
are included with these be in distinct fields?

Neil Lennertz nlennertz@healthcarepartners.com

If we were an MSSP ACO last year and a Next Generation ACO N/A N/A
now, do I register the new ACO TIN and legal name when I
request the SO role for this new organization?

Will the beneficiary sample file delivered on January 8th as N/A N/A
with the file from the Web Interface? Is there a template for
the MFT file so that we can update our loading processes?
Neil Lennertz nlennertz@healthcarepartners.com

Considering the number of questions about provider NPIs and N/A N/A
the differences in patient file formats between the WI and
MFT, I think this should be explicitly addressed in the webinar.

A response to my question about MFT patient download file N/A N/A

said that the file will be the same format as last year. I am
confused. Last year it was XML but as far as what has been
said, there is no XML this year. Please clarify what is meant by
the same format?

Please verify- if a beneficiary has a colon screening that was As long as the coloretal cancer screening is Debra
not provided under the Medicare Benefit (for example they documented in the medical record and meets the Kaldenberg
had the screening using their Aetna Insurance less than ten requirements identifed in the 2017 PREV-6
years ago would they be elidigible for inclusion in the measure document it can be used for submission
numerator if they self report the date/result of the screening? purposes.
Or do we need to obtain the documetation for the screening in
order for the beneficiary to be included in the numerator?

Can a beneficiary be included in the numerator for eye exam if The following information is included on page 11 Debra
they self report the date/result of the eye exam? Or does the of the 2017 DM measure document: Patient Kaldenberg
provider need to have the documented results from the eye Reported Requirement: Date (year) and
doctor? Nichole Schultz nschultz@piccorp.com result/finding. This information must be included
in the medical record documentation.

Are the 2018 Web Interface Measures List posted anywhere N/A N/A
online at this time? How do we know what measures are
required for 2018? When will they be ready if not availble at
this time?

When will the Narrative Measure Specificiations & N/A N/A

Performance Flows for 2018 be available? Where can these be
found?

can you provide clarification of which dx meet the ASCVD dx Please refer to the PREV Coding document, Angela
for the statin therapy measure? Pamela Kanda pamela.kanda@csmns.org Denominator Codes for the ASCVD_CODEs Stevenson
included for PREV-13.

As you answered, number like 17, 8 for confirmation are N/A N/A
replaced by yes/No value in 2017 reporting year. Question is
last year there was information to know whether patient
submited is complete or incomplete, do this year can we
expect any such document? If yes, when will it published?

Pankaj Pawar pankaj.pawar@citiustech.com

However, I do not see any specification there as it was released N/A N/A
in 2016, the link for which is mentioned
belowhtps://qnpapp.qualitynet.org/cs/pqrs/documents/gpro/
GPROXMLSpec2016/index.htmAre we expecting something
similar for 2017 as well? Or are the documents on the QPP
website the final ones?

Is there a deadline for creating the EIDM accounts for the Web Please create and verify your EIDM Accounts by Kenneth
Interface Submiters? Patricia Fustino patricia.fustino@baycare.org Janury 8 2018. This will allow time to resolve any Howard
unexpected problems

How will reporting for APM-MIPS reports work in the web N/A N/A
interface since such providers are not pure MIPS reporters? Patrick Gannon gannonp@southcoast.org
Thank you.

Is this information, solely, for submitting Quality Measures? Or N/A N/A

does this also include MIPS ACI? If it does NOT include MIPS
ACI, are there separate webinars for enrolling and submitting? Paul Varghese paul.varghese@utsouthwestern.edu

Will you post (to the QPP Resource Library) an excel template N/A N/A
that includes the drop down options for allowed answers, built
in hints and built in logic. The current template does not
contain these.

Will the verification code be sent via email I dont have my cell N/A N/A
phone atached to my EIDM account
How can we obtain a list of the text options for the excel N/A N/A
upload (vs the old xml numeric responses)? Pennilee Shortsleeve pennilee.shortsleeve@onecarevt.org

Answer - Sarah Grallert Yes, these dates will be available on N/A N/A
1/8 within the Web Interface (but not in the beneficiary
ranking file). I'm not certain of your 3rd question. We don't
limit the discharges.I have a follow up to this we were shown
that the discharge dates were included in the excel download
patient list

We are a system with 2divisons signed up: urgent care and N/A N/A
Nursing Home for the program. Can one person assigned as
the data submiter role submit data for both divisions?

Pradeepa Arivazhagan parivazhagan@essenmd.com

For overlapping patients between ACO and MIPS reporting, N/A N/A
should we report data for these benefeciaries through both?

Will you be able to upload an excel with patient information as N/A N/A
well as input data into the WI? So if uploading an excel, will
that populate the WI in real time?
Rebecca Eastman reastman@challc.net

Did I read correctly that this year the SO may download the N/A N/A
sample set as well as be able to input into the WI?
1. Will Care 1 dates be provided at the same time as the Yes, these dates will be available on 1/8 within the Sarah Grallert
beneficiary file/list on 1/8/2018? 2. If yes, will the dates be in Web Interface (but not in the beneficiary ranking
the same file as the beneficiary file or a separate file? 3. What file). I'm not certain of your 3rd question. We
is the total number of Care 1 dates for each beneficiary? Rebecca Ten Hoopen rtenhoopen@abs-tpa.com don't limit the discharges.

Where in the Excel spreadsheet would be the place to input N/A N/A
the ticket number if we have requested an exception?
Rebecca Eastman reastman@challc.net

When will the 2017 WI Quality Q&A's be published? N/A N/A

When Care 1 was utilized several years ago for reporting, I N/A N/A
believe the most dates that any one beneficiary had was 12. Is
there a limit, or can you tell us how many total dates we can
expect to see for any one beneficiary? Thank you.
Rebecca Ten Hoopen rtenhoopen@abs-tpa.com

Will we be able to obtain/download a report with just the Care N/A N/A
1 dates from the web interface on 1/8/2018?
Are quick reference guides available for the 2017 measures as N/A N/A
have been available in past years? Rene Olavarrieta rolavarrieta@hcnetwork.org

would you repeat the codes for Prev 5 for 3D mamo? Rhonda Smith robsmith@novanthealth.org N/A N/A
My understanding is that Excel File will be populated with N/A N/A
Claims Data up to the end of Oct, 2017 (such as if a Patient
was billed for a Flu Vaccine). Do we have more information
available about what type of Claims Data will be automatically Robert Dean robert.dean2@snch.org
populated in the Excel File? Thank you

Simple question that I didn't see addressed earlier. What is the N/A N/A
web address for logging into the WI? Will there be a new
option on the QPP homepage that isn't there yet?

Ryan Maccubbin ryan.maccubbin@msj.org

Is it possible to get actual URLs? There is no "2017 MIPS N/A N/A
Quality" section of the QPP Resource Libary like the slide says.

Is the "Sign In" option supposed to be available on the QPP N/A N/A
web page as an indication that EIDM access is properly set up,
or is this option going to appear only when the Web Interface
is available for access? Sean Cheetham cheeths@cmhc.org

Are there more files available with the Sample file beyond the The beneficiary samples will be available within Sarah Grallert
Excel template file? the WI itself.
Can you enter some data via the Web Interface and some data The latest data provided to the CMS Web Interface Ralph
through file upload? Will one overwrite the other? for a beneficiary is the data that is used. If the file Trautwein
upload contains the latest submission of data that
will be used. If manual entry is performed after an
upload that data entered manually will be used for
the beneficiary. Last in data is the data that is
used.

if we upload a file with some lines of data and then manually Shannon Huggins shannonhuggins@mhd.com N/A N/A
enter other beneficiary line information will that line that is
NOT entered manually be overwriten to blank? Since you
stated that last in data is the data that is used is that by line
item or in total?

Is the QRR ticket number on the excel sheet to be used only if N/A N/A
we called to report and issue? When else would we need to
include the QRR ticket number on the excel spreadsheet?

To clarify, for denominator 2 of PREV-13 the patient will have
LDL-C>190 OR diagnostic code consistent with Familial
hypercholesterolemia or Pure hypercholesterolemia that are
given (eg if a patient has one of these diagnositic codes but
only LDLc are <190 are they included?)?
Shari
Yes, either of these conditions would be Debra
considered denominator eligible for Risk Category Kaldenberg
2: Patients aged ≥ 21 years at the beginning of the
measurement period who have ever had a fasting
or directlaboratory result of LDL-C ≥ 190 mg/dL OR
Cummins scummins@skagitregionalhealth.org were previously diagnosed with or currently have
an activediagnosis of familial or pure
hypercholesterolemia

Is it possible to confirm if the file format that our Epic N/A N/A
Abstraction Extract tool creates meets the criteria for upload in
the CMS interface? Specifiallly prior to the test period in
January

Will ACO-44 (Imaging for Low Back Pain) need to be reported N/A N/A
for PY2017? Shaun Coleman shaun.coleman@bswhealth.org
Can we confirm our Excel Generated Epic Extract (appropriated N/A N/A
CMS format based on new 2017 specifications) prior to the
testing period? Have some concerns about the turnaround
time if Excel file is NOT able to upload.

For Measure ACO12 - Care 1 Med Rec measure, our parent N/A N/A
organization relied on the standard that the (EHR) med list
would be automatically updated at the time of discharge so
any subsequent OP appointments would already affect the
changes made during the admission therefore the language
"reconciled" would not be present. Can you confirm if that
would be acceptable or that the medical record needs to Shawntel Burke shawntel.burke@onecarevt.org
contain the reconcilliation of discharge meds to meet the
measure?

Will the template include the GPRO specs? Can you please clarify your question for us? Olivia Berzin
Thanks!
Can the template be uploaded by disease module? The N/A N/A
previous webinar said that each new file would over write the
previous file. Was not sure if previous info would be saved
Sheree Arnold sarnold@chsbuffalo.org

In previous years we received a document of the GPRO specs. N/A N/A

We originally used an xml format for upload. Will the
specifications related each measure be a part of the template?

For Care-1, if the discharge is from another inpatient facility, N/A N/A
we may not have the data to confirm it. We may have to rely
on patient memory for dischage date and/or whether the stay
was inpatient. Please provide guidance on how to submit in Sonali Tamhankar tamhankar.sonali@gmail.com
case of knowledge gaps about outside inpatient admissions.

when will the web interface Q&A's be posted? In years past, N/A N/A
this was posted in November....
if you are able to prepopulate Influenza why are you not able N/A N/A
to prepopulate other measures with claims data such as Stacey Arens-Wilson arenss@health.missouri.edu
mammography, colonoscopy, pneumococcal.. thx

Will the test web interface and sample be available first thing N/A N/A
in the morning on the 8th of January? Stacy Munroe munroes@ccf.org

Amy - the QPP helpdesk said ONLY names will be in the Excel Hi Stefanie, Just to clarify - the NPIs themselves Amy Mills
export file. will not be provided in the Excel Template, but will
be available in the Beneficiary Sample Excel file
that we deliver to ACOs via MFT. The NPIs will also
be availble to Groups within the Web Interface
itself.

Sara - the excel template does show "Clinic ID" I assume this is N/A N/A
perhaps the TIN the other person asked about - where the Stefanie Honeycut shoneycut@primaris.org
patient received most of their primary care services?
 Stefanie Honeycut shoneycut@primaris.org

why is there no consistency to the answers that can populate N/A N/A
the Excel template? I have seen at least 3 different variations
for den exception medical reason.

can you please explain again how a beneficiary could appear in N/A N/A
more than one file?
When I can obtain a 'Physcian Quality and Value Programs' Please make sure you are using your active EIDM Kenneth
Role? Logge into EIDM but the menu item (My Access) is NOT account and NOT an EUA account. If in doubt Howard
available yet... support@popmso.com please contact the QPP service desk for assistance
Stephan Hyun to verify the credential.

Is there a sample program fill the Excel template? N/A N/A

Can software vendors supporting ACOs gain access to a test N/A N/A
environment?
If there is an error in one of the rows (e.g. "beneficiary not Only the data that is in error will be rejected. Ralph
found", will the entire file be rejected, or will just that row be Good data in the file will be used. Trautwein
rejected? Steve Daniels steve@ablehealth.com

Are there plans to allow ACO data submission via the QPP N/A N/A
Submission API at any point in the future? I know MIPS and
CPC+ are currently supported.

Why isn't there a separate Excel file for each measure? There is a seperate Excel coding document for the Debra
measures but is coding only. Both CARE measures Kaldenberg
are included in one coding document and all PREV
measures are included in one coding document.
The old data guidance information is now
identified as submission guidance and is included
in the measure documents. Thanks

Susan Gentilli susan.gentilli@allina.com

Historically, we received separate files for each measure and N/A N/A
downloaded and uploaded separate .xml files. Why are there
not separate Excel files for each measure?

There is conflicting information on the BMI measure re: 6 vs. N/A N/A
12 mos BMI and follow-up. Some of the CMS documentation
suggests 12 mos BMI and 6 mos follow-up and other indicates
12 and 12 mos. Please clarify.

Is it possible to add the NPI field to the Excel Templete before N/A N/A
Jan 8th? Terance Brooks terance.brooks@via-christi.org

The data that we populate the Excel Spreadsheet with and N/A N/A
upload during the practice time frame of 1/8/18-1/19/18 will Terri Vaal tvaal@mhhcc.org
be erased, is that correct?

Is the sample provided on January 8th, the final patient The sample provided on January 8th (both the Sarah Grallert
ranking file or will there be changes to be expected at a later patient ranking file as well as what is
date? Tiffany Go tgo@cal-aco.com downloadable from the WI) is the final sample.

If we submit data for MORE than the 248 patients (e.g. for ALL N/A Ralph
patients on the list), is our score based only on the first 248, or Timothy Heilmann theilmann@susquehannahealth.org Trautwein
on ALL patients

So a non-billed telephone call by RN or pharmacist is Yes, a phone call within 30 days of the discharge Debra
considered a telehealth encounter for purposes of CARE-1? would be accepted as long as the requirements of Kaldenberg
the measure have been met and documented in
Tony Ryder tony.ryder@virginiamason.org the medical record. Thanks

where and when will the slides from the presentation be N/A N/A
posted Tricia Hoffmann trish.hoffmann@aaneel.com

Here is my comment (not a question): CMS not supporting N/A N/A

XML for WI is a significant digression from any atempt by CMS
toward keeping current with technology.

CMS, please be aware that your Excel template on the QPP N/A N/A
Resource page lacks cell (column) constraints. For example, if
there is a cell in which you will only allow "Yes" or "No", that
constraint isn't presented in the template which has a Trudie Pearcy trudie-pearcy@uiowa.edu
12/8/2017 on your webiste date as of right now. Meaning in
the template if an ACO wants to enter the word "Snoopy" in a
Yes/No cell, there is nothing to stop them. I suggest you
enforce constraints in your Excel to avoid serious data integrity
issues.

For data submission for the transition year, if a group reporting N/A N/A
under web interface reports on 1 or 2 quality measures they
avoid any payment adjustment correct?

Web interface groups are submitting for a full calendar year, Tyler Moser tyler.moser@kernmedical.com N/A N/A
but are we required to report on all measures during the
transition year to avoid payment adjustment?

Is XML data submission still supported as it has been in XML data submission will not be available for Amy Mills
previous years? William Martin will.martin@tpmgpc.com PY2017.