Clinigence and Flatiron 2017 MIPS Quality Enrollment Form
Use this form to select Clinigence as your MIPS Quality reporting vendor.
Email address *
Clinigence Partner Name *
The name of the Clinigence partner from whom this service is being purchased
Your answer
Flatiron Coupon Code *
This code is provided to the practice by Flatiron.
Your answer
Your Name *
Your answer
Your Phone Number *
Your answer
Practice Name *
Your answer
Practice TIN *
The TIN used to file Medicare PartB claims.
Your answer
Street Address *
Only required for new sites.
Your answer
City *
Only required for new sites.
Your answer
State *
Only required for new sites.
Your answer
Zip Code *
Only required for new sites.
Your answer
Phone Number *
Only required for new sites.
Your answer
Practice Type *
Only required for new sites. For example: Family Medicine, Pediatrics, General Surgery, Cardiology, etc.
Your answer
Group or Individual Provider Participation? *
Are each of your providers participating as a group (GPRO) or as individual providers. If participating as a group all providers submitting under your TIN will receive the same score. If participating as individuals each TIN/NPI combination will be scored based on the patients attributed to the NPI.
90 Day or Full Year Submission? *
Participating Providers *
List the providers who will be participating in the program. Include the provider name and NPI.
Your answer
EHR Name *
Your answer
Estimated Number of Patients Seen in 2017
An approximate number of unique patients who will have been seen in 2017. This can be based on your 2016 numbers if you expect them to be about the same. We use this count to ensure that we are finding all of your patients based on the data you have provided.
Your answer
Additional Information
Include anything else we should know about your practice.
Your answer
Measure Selections and Submission
Measure Selection: Clinigence has partnered with Flatiron to calculate and submit the following measures via registry. Your practice and providers will be configured to measure all of these measures.

(Process, High) CMS na/QID 47: Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

(Process) CMS 147/QID 110: Preventative Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

(Process) CMS 127/QID 111: Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

(Process) CMS 130/QID 113: Colorectal Cancer Screening: Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer.

(Process, High) CMS 568/QID 130: Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

(Process, High) CMS 157/QID 143: Oncology: Medical and Radiation - Pain Intensity Quantified: Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

(Process, High) CMS na/QID 144: Oncology: Medical and Radiation - Plan of Care for Pain: Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain

(Process) CMS 138/QID 226: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

(Outcome, High) CMS na/QID 457: Proportion Admitted to Hospice for less than 3 days (in QID number order): Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there

Measure Submission: The 2017 reporting period is from January 1, 2018 through March 31, 2018. Clinigence will submit all measures for all participating providers in the practice or the GPRO. CMS will use the 6 most advantageous to each provider or GPRO.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Clinigence. Report Abuse - Terms of Service