MIPS, are you ready? The Merit-based Incentive Payment System.

Stethoscope and MIPS documents

As mentioned in a previous blog, MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment System, or “MIPS”.  The purpose of MIPS is to reimburse physicians based on quality and cost rather than volume.

Providers can take one of two tracks in participating with the Quality Payment Program.  One of the tracks is to participate through an Advanced Payment Model (APM) which is for providers who provide services in one of five scenarios: a) Shared savings Program (tracks 2 and 3); b) Next Generation Accountable Care Organization (ACO) model; c) Comprehensive ESRD Care, d) Comprehensive Primary Care Plus, or e) Oncology Care model.  The other track, which all other providers must use is the Merit-based Incentive Payment System (MIPS).


Does MIPS apply to me?

MIPS probably applies to you if you are a:

  • Physician (MD/DO or DMD/DDS) or
  • Physician Assistant or
  • Nurse Practitioner or
  • Clinical Nurse Specialist or
  • Certified Registered Nurse Anesthetist
  • and not participating in an Advanced APM

MIPS does not  apply to you if:

  • You are a qualified participant in an APM or
  • You are in your first year in the Medicare Part B physician fee schedule or
  • You treat less than 100 Medicare beneficiaries or have less than $30,000 in Medicare charges (for 2017 qualification year this goes up for 2018) or
  • You are part of a hospital or facility (such as ambulatory surgical center, lab, etc.)


MIPS categories.

MIPS category: Quality – The quality category has two sets of measures: 1) The CMS-calculated measures that are currently determined as part of the Value Modifier and 2) Measures submitted by providers.  In 2017 CMS will use just one measure for the CMS-calculated measures – that is All-cause Hospital readmissions.

For the measures submitted by providers there are over 200 measures from which to choose a minimum of six to submit.  These measures will look familiar to you because they are replacing the PQRS measures.  CMS has created a series of specialty measures so the providers in each specialty will have at least six measures that are meaningful to them.  As an example, one measure that everyone should recognize is: “Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention”.  Anyone who has submitted PQRS or measures for Meaningful Use should have these measures already being calculated for them. For 2017 the minimum performance period for gathering the data is 90 days.  The quality measures cannot be submitted through attestation.  Methods for submission for the Quality Measures are:

  • Qualified Registry
  • Qualified Clinical Data Registry Reporting (QCDR)
  • Electronic Health Record (EHR)
  • CMS Web Interface (groups with 25 or more MIPS clinicians)
  • Administrative Claims
  • File Upload on Quality Payment Program website (QPP data format or QRDA III)
  • Consumer Assessment of Healthcare Providers and System (CAHPS) for MIPS Survey

You must be using an EHR that has been certified for 2014 or later.  Note that many EHR systems do not have the ability to submit the Quality Measures or even create a file in QPP format or QRDA III format. So, using a qualified registry may be your only choice.  Each Quality Measure counts at a minimum of 3 points, but can count higher.  This is important because, given the fact that, in 2017 all you need is 3 points to avoid a penalty on your 2019 Medicare reimbursement, you can avoid a penalty by submitting only one Quality Measure.  As a matter of fact, all you must do is submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), and you can avoid a downward payment adjustment.   The data must be submitted between January 1, 2018 and March 31, 2018.

MIPS category: Advancing Care Information (ACI) – replaces the EHR Incentive Program for eligible professionals – also known as Meaningful Use.  In order to pass this ACI requirement you must be able to say yes to the five following ACI measures:

  • Security Risk analysis
  • Electronic Prescribing
  • Provide Patient Access
  • Send a Summary of Care Record
  • Request/Accept a Summary of Care

There are two parts to scoring in this category.   There is a base score and a performance score. In order to receive a base score for each measure you must use EHR technology for it and have at least one patient in each measure.  The Security Risk Analysis measure is submitted by indication of a “yes” or “no” The other four measures are reported as a numerator over a denominator.  Each measure must have a minimum of a 1 in the numerator. If you do not meet the five base measures, you will fail in this category.

If you meet all of the measures in the base category you can earn additional points by performing some or all of these bonus performance score measures, all submitted with a numerator and a denominator: a) Patient Specific Education, b) View and/or download or Transmit (VDT), c) Secure Messaging, d) Patient Generated Health Data, e) Clinical Information Reconciliation, f) Immunization Registry Reporting, g) Registry Bonus Measures, h) Syndromic Surveillance Reporting, i) Electronic Care Reporting, j) Public Health Registry Reporting, and k) Clinical Data Registry Reporting.

MIPS category: Clinical Practice Improvement Activities (CPIA) – rewards practices that undertake improvement efforts such as:

  • Care Coordination
  • Beneficiary Engagement
  • Patient Safety

There is a total of 93 activities from which to choose. The full list of MIPS activities can be found on the CMS website.  Some examples include:

  • Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
  • Engage patients and families to guide improvement in the system of care.
  • Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).
  • Participation in a QCDR, that promotes use of patient engagement tools.

In order to pass in the CPIA category in 2017 a provider needs four of the activities over a 90-day period if they are in a group of 15 or more providers.  If they are in a group of less than 15 providers they only need to do two of the activities.

MIPS category: Resource Use is based on Medicare Claims data, meaning that there is no additional data for the practice to collect. In 2017 the percentage that counts against your total MIPS score is 0%.  In subsequent years it goes up so that by 2019 it counts for 30%.  CMS examines the claims data to determine the cost of caring for patients attributed to the practice. Patients are attributed to a practice they visit most often for primary care services.


MIPS  what is new for 2018?

There are quite a few changes for 2018 (affecting Medicare payments in 2020).  The weighting of the four performance categories towards your final score has changed.  In 2018 the changes are as follows:

  • The Quality category weighting goes from 60% to 50%
  • The Advancing Care Information category stays at 25%
  • The Clinical Practice Improvement Activities stays at 15%
  • The Resource Use category goes from 0% to 10%

The MIPS Payment Adjustment goes from -+4% to -+5%, meaning that those providers who do not submit any data will get a 4% negative adjustment in their Medicare reimbursement for 2020.   Performance Period – In 2017 you only need to choose a minimum period of 90 days for data collection for your quality measures whereas in 2018 you must report on the full year.   In 2017 you can be excluded if you had less than 100 Medicare Part B patients or less than $30,000 in Medicare Part B allowed charges.  For 2018 the threshold is increased to 200 Medicare Part B patients or $90,000 Medicare Part B allowed charges.

CMS has allowed the creation of a virtual group for participation if you are a small practice but still above the participation threshold.

The performance threshold for avoiding a penalty has been raised from 3 points in 2017 to 15 points in 2018.  However, you will receive credit of 5 points if you are in a practice of less than 15 providers.  This means that, if you are in a small practice, you will potentially need to submit a minimum of four quality measures in order to avoid a penalty (if you do not submit for any of the other categories).  Note that the minimum number of points awarded for quality measure is still 3 points even if the measure does not consider to be complete as far as the amount of data in it.

Although you can still use an EHR system that is either 2014 or 2015 certified, you will receive a 10% bonus if your system is 2015 certified.  Other changes in 2018 reflect relief for practice that are affected by a natural disaster as well as relaxed rules for APMs.

If you have any questions about the information covered in this discussion or would like additional information on how to succeed for MIPS please contact The Fox Group.

When you need proven expertise and performance

David Pack, MS, Senior Consultant

Mr. David B. Pack has over 30 years’ experience in the Healthcare Software industry as a Manager and Software Technologist. Achievements include founding, building and growing an EHR Software Company.

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