2025 MIPS Startup Guide

We know you’re already an expert in providing patient care in compliance with Medicare regulations. The following information and instructions are provided so you get the most out of the tracking and reporting features available in Net Health WoundExpert | The Most Trusted Wound Care EHR  for your 2025 MIPS reporting 

Note: To access the links below, sign into Net Health WoundExpert in another browser tab prior to clicking the link. 

Information 

In our How-To Documentation, you can find all the information needed for MIPS reporting for Promoting Interoperabililty (PI) for the 2025 Performance Year and Outpatient Physician eCQM Measures for the 2025 Performance Year, Traveling Physician MIPS CQM for the 2025 Performance Year and Medicare Access and CHIP Reauthorization Act (MACRA) – 2025 Edition . These topics list all measures supported by Net Health WoundExpert and specifically highlight the fields used to capture measure data. 

Remember, you can always access this How-To Documentation by logging into Net Health WoundExpert, hovering over your name in the upper right-hand corner of the screen and selecting How-To Documentation from the drop-down menu.

Your MIPS 2025 documentation and reporting checklist  

  1. Ensure you have set up your HARP Account. Contact the QPP Helpdesk with any questions at 866-288-8292  (see https://harp.cms.gov/login/help)
  2. Check your eligibility status, see: How MIPS Eligibility is Determined Intro
  3. Determine if you are reporting as an individual or as a group, see here: Individual or Group Participation
  4. Determine your reporting options.  Net Health WoundExpert supports the traditional MIPS reporting. Traditional MIPS Overview
  5. Review the 2025 Exceptions to meeting Merit-based Incentive Payment System (MIPS) program requirements here: QPP Exception Applications Intro
  6. Review the changes to performance thresholds, payment adjustment, and reporting categories for Traditional MIPS Reporting. Traditional MIPS Overview
  7. Understand the Medicare Access and CHIP Reauthorization Act (MACRA) – 2025 Edition. Medicare Access and CHIP Reauthorization Act (MACRA) – 2025 Edition
  8. Understand the MIPS category requirements and timeframes for each category captured within Net Health WoundExpert
     • Outpatient Physician eCQM Measures for the 2025 Performance Year
    • Traveling Physician MIPS CQM for the 2025 Performance Year
    • Promoting Interoperabililty (PI) for the 2025 Performance Year
  9. Align your documentation workflows.
  10. Review your MIPS reports early and often.
  11. Report your MIPS documentation timely.  The submission window opens for the 2024 performance period January 2, 2025. CMS submission window closes for the 2024 MIPS performance year on March 31, 2025.
  12. Maintain your final MIPS Reporting in a data validation and audit (DVA) folder NOTE:  For the purposes of auditing, CMS may request any records or data retained for the purposes of MIPS for up to 6 years from the end of the MIPS performance period.

Instructions 

When you see “⭐CONFIGURED FOR PI AND QUALITY” at the top of your Net Health WoundExpert facility, that means that all the behind-the-scenes features are enabled and ready for your customization. 

Depending on the measures you plan to report on, there are a couple of additional configurations you may choose to make. Don’t worry – each configuration listed below includes a link with detailed instructions in our How-To Documentation. 

Promoting Interoperability (PI) Measures that Require Additional Set-up 

  • Promoting Interoperabililty (PI) for the 2025 Performance Year
  • E-Prescribing:  For providers with the authority to E-Prescribe, set “E-Prescribe” to YES in their Physician Contact List entry.  
  • Provider to Patient Exchange:  Enroll patients or their authorized representative for the Patient Portal.  
  • Health Information Exchange (formerly Transfer of Care Summary)
    Set up discharge statuses that constitute Transfer of Care.  If you do not already have an SES Direct Email account for each physician who will be participating in this measure, contact Client Services to purchase an account. Any Direct Email you may have through another EMR (e.g. Athena, Cerner, etc) may not be supported to send secure messages through the platform. Input Direct Email addresses into the Contact List entries of any Physicians who will be receiving Transfer of Care Summaries. Note that those you email do not have to have SES Direct Email addresses. 
  • Public Health and Clinical Data Exchange
    Our clients will be meeting the exclusion for these measures, so we will devote our time, energy, and resources to developing other application features that are most important to our clients, and we will not be supporting the Public Health and Clinical Data Exchange measures. To review the exclusions, please read here. 
  • Alerts
    Alerts are enabled by default. Facilities must not disable all the MIPS alerts to continue to be considered MIPS-enabled.  If you are filtering alerts by role, the appropriate roles must be added to each user’s account.  Edit Alerts

Helpful information in the How-To Documentation is listed below: 

View, Download, and Transmit (formerly Provide Electronic Health Information) 
Enroll patients or their authorized representative for the Patient Portal. Patient Portal Enrollment 

Patient-Specific Education
Input diagnoses, medications, and labs to trigger educational resources to display appropriate educational topics.  Patient/Caregiver Education

Secure Electronic Messaging
Enroll patients or their authorized representative for the Patient Portal.  Patient Portal Enrollment

eCQMs for Outpatient Facilities that Require Additional Set-up
Measure 122: Diabetes: Glycemic Status Assessment Greater Than 9% 

– Hemoglobin A1c/Hemoglobin.total in Blood by HPLC
– Hemoglobin A1c/Hemoglobin.total in Blood
– Hemoglobin A1c/Hemglobin.total in Blood by Electrophoresis 

Measure 139: Falls: Screening for Future Fall Risk 
When charting the follow-up care for these measures, either of two visit documents can be used: 

  • On the Physician Orders, the Other Orders tab can be used. 
  • If corresponding SNOMED codes are input in the Plan of Care Admin, the Plan of Care can be used. 

MIPS CQMs for Traveling Physicians that Require Additional Set-up 

Measure 1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 

– Hemoglobin A1c/Hemoglobin.total in Blood by HPLC
– Hemoglobin A1c/Hemoglobin.total in Blood
– Hemoglobin A1c/Hemglobin.total in Blood by Electrophoresis  

Other MIPS Documentation 

Patient Portal
The documents viewable by patients can be configured via Facility Admin > Facility Setup > Patient Portal Setup.  

Family History SNOMED
Family History items and No Known History items can be codified within the Document Options for Family History. PFSH – Medical/Surgical History Admin

Patient Demographics
Many measures rely on the patient having accurate information for their date of birth, ethnicity, race, gender identification and sexual orientation.  Add Patient/Modify Patient

Plan of Care Admin
The Clinical Summary can indicate whether a part of the plan of care is part of the treatment, goal, or assessment item. To better indicate this information on the Plan of Care, we have included ways to update this information in the Plan of Care Admin. Plan of Care Admin

Additionally, items can be indicated as the correct SNOMED within the Plan of Care Admin. If corresponding SNOMED codes are input in the Plan of Care Admin, the Plan of Care can be used. 

You can increase your staff’s measure capture success by configuring the Workflow Facility Admin to include documents that contain the questions relevant to MIPS measures. If you need assistance troubleshooting, reach out to Client Services at (844) 464-9348 option 2, woundcare-support@nethealth.com or by using clicking ‘Feedback’ under Technical Support in Net Health WoundExpert.