MACRA and MIPS: Frequently Asked Questions

Wading through reams of information on MACRA and MIPS can be daunting. To provide more clarity, we have developed a series of questions and answers for physicians and practices. The FAQ was created by experts from Medical Advantage Group (MAG), a subsidiary of The Doctors Company. MAG simplifies the delivery of efficient, high-quality healthcare for medical practices, health centers, physician organizations, hospitals, and health systems.

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  • I am overwhelmed with MIPS. Where do I start?
  • MIPS is a large and very complicated reporting program, and tackling it in one fell swoop is virtually impossible. Focusing on the three reportable MIPS categories (Quality, Improvement Activities, and Advancing Care Information) one at a time is a much safer and more manageable strategy.

    Your primary goal for MIPS in 2017 is to avoid a negative payment adjustment in 2019. Fortunately, CMS has made this an achievable goal for every provider. By reporting a minimal amount of information in just one of the MIPS categories, you will protect yourself against a negative 4 percent penalty.

    Here are the minimum requirements for each category:

    • Quality—submit 1 clinical quality measure with at least 1 patient in the numerator.
    • Improvement Activities—complete and attest to 1 of the 92 approved Improvement Activities.
    • Advancing Care Information—report on the 4 required measures of the 2017 Transition Objectives and Measures list.

    Deciding which category to report will depend on whether you have successfully reported in the PQRS or the Medicare and Medicaid EHR Incentive (formerly called Meaningful Use) Program.

    If you have previously reported to the PQRS, you should have processes in place to collect and report on at least one Quality measure. Verify that your previously reported measures are on the list of approved MIPS quality measures for 2017, and select your submission method.

    If you previously attested for Modified Stage 2 of the EHR Incentive Program, you should have the processes in place to meet the four required measures on the 2017 Advancing Care Information Transition Objectives and Measures list. Be sure that you can meet the Health Information Exchange measure on at least one patient if you have been excluded from this measure in the past.

    If you have not previously reported to the PQRS or the EHR Incentive Program, select one of the 92 approved Improvement Activities and begin implementing your chosen activity. You can download an Excel spreadsheet with more information on each activity, including required actions and suggested documentation, by clicking on the MIPS Data Validation Criteria link at https://qpp.cms.gov/about/resource-library.

    Once you are sure you can report the minimum amount of information in at least one category, you can begin the ambitious goal of trying to earn an incentive for 2019. Since the Quality category has the highest weighting (60 percent) on your overall MIPS score—which ultimately determines your payment adjustment—it makes sense to start there.

    Note: CMS recognizes that providers are feeling overwhelmed, so they have taken two approaches to educate and assist clinicians in meeting QPP requirements.

    First, CMS has created the QPP website (https://qpp.cms.gov), which contains a wealth of information about both tracks of MACRA: the Advanced APMs and MIPS. If you have not visited this site yet, it should be your first step to learning more.

    Second, CMS has developed technical assistance programs in every state to offer high-quality, no-cost direct support to help providers plan and implement their MACRA strategies. Visit https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf to determine which program best fits your practice circumstances and needs, and then follow up with the designated organization in your area to learn more.

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    • How do I know if I have to report MIPS?
    • You are required to report MIPS if you are a physician (MD, DO, DPM, DC, DDS, DMD, or OD) or an advanced care nurse (CNP, PA, CNS, or CRNA).

      You are not required to report MIPS if:

      1. this is your first year billing Medicare; or
      2. you are a low-volume provider with less than $30,000 per year in Medicare Part B charges or have fewer than 100 Part B patients*; or
      3. you are a Qualifying Participant in an Advanced APM.

      *You can check your MIPS participation status on the individual and group level with regard to your low-volume status at https://qpp.cms.gov/participation-lookup.

      Note: Low-volume status is evaluated at both the individual and group level.

      For reporting MIPS categories to CMS, the following submission methods are available for each MIPS category.

Performance Category Data Submission Mechanisms
Quality Claims (individuals only)
Qualified registry
QCDR
EHR
CMS web interface (groups only, 25+ NPIs)
CAHPS for MIPS survey (groups only, 2+ NPIs)
Improvement Activities Attestation
Qualified registry
QCDR
EHR
CMS web interface (groups only, 25+ NPIs)
Advancing Care Information Attestation
Qualified registry
QCDR
EHR
CMS web interface (groups only, 25+ NPIs)
  • Here is a brief explanation of each of these methods.

  • Attestation: Providers will log in to the QPP reporting portal (not yet available) to report applicable information. This may take the form of answering yes or no questions, entering numerators and denominators, and selecting from a list of improvement activities. Please note: this method is not available for the Quality category; you cannot simply attest to your quality measure numerators and denominators. You must submit them via one of the other approved submission methods.

  • Claims: Clinicians report designated quality data codes (CPT Category II or G codes) on their Medicare claims forms to indicate when a quality action has or has not been performed on an applicable patient.

  • EHR: Clinicians can report using either self-submission or vendor-submission. For self-submission, the provider or practice will obtain a QRDA III file from the EHR vendor then upload the file via the QPP reporting portal (not yet available). For vendor submission, the EHR vendor will collect and report the information on the provider or practice’s behalf.

  • Qualified registry: A CMS-approved entity collects clinical data or quality data codes from a provider or group and submits them to CMS on their behalf.

  • QCDR: A CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. The entity is usually associated with a specific specialty or subspecialty. The QCDR reports the appropriate data to CMS on the provider’s or group’s behalf.

  • CMS Web Interface: A secure Internet website where groups of 25 or more MIPS clinicians report quality data to CMS. The CMS web interface is partially prepopulated with claims data from the group’s attributed Medicare Part A and B beneficiaries. The group then completes the data for the prepopulated Medicare patients.

  • CAHPS for MIPS: A CMS-approved survey vendor collects data from the practice’s patients about their experience of care, and then submits that data to CMS on the group’s behalf.

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  • Do I have to notify CMS of which categories I’m going to report, or how I am planning to report?
  • You do not need to tell CMS which categories or measures you are planning to report. You also do not need to notify CMS of your intention to report as an individual or as a group.

    The following submission methods do not require prior notification to CMS: attestation, claims, qualified registry, QCDR, and EHR.

    CMS does require notification from practices that intend to use the CMS web interface or CAHPS for MIPS submission methods. However, the deadline for that notification was June 30, 2017. If you have not already registered for these methods, you will need to select another option.

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  • What happens if I just do not participate in MIPS?
  • If you are exempt from MIPS because you are new to Medicare, meet the low-volume threshold, or are a qualifying participant in an Advanced APM, there will be no consequence for choosing not to participate in MIPS.

    If you are not exempt from MIPS and you fail to report at least the minimum amount of information for 2017, you will automatically receive the full 4 percent penalty on all of your Part B payments for payment year 2019.

    The penalties for nonparticipation in MIPS increase each payment year and are as follows: 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022. Penalties for years after 2022 have not yet been decided, but will presumably remain at a minimum of 9 percent.

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  • I do not have an EHR. Can I still participate in MIPS?
  • Yes, you can still participate in MIPS by reporting information in the Quality and Improvement Activities categories, with the potential to earn up to 75 (out of 100) points and receive a positive payment adjustment in 2019.

    You will not be able to report for the Advancing Care Information category without using a certified EHR. Unless you qualify for automatic reweighting or a hardship exception, you will receive an Advancing Care Information score of zero.

    The following eligible clinicians will automatically have their Advancing Care Information points reweighed to the Quality category:

    • Nurse practitioners.
    • Physician assistants.
    • Clinical nurse specialists.
    • Certified registered nurse anesthetists.
    • Hospital-based clinicians.
    • Clinicians who lack face-to-face interactions with patients.

    Other MIPS-eligible clinicians can apply to have their Advancing Care Information points reweighted to Quality based on the following hardship reasons:

    • Insufficient Internet connectivity.
    • Extreme and uncontrollable circumstances.
    • Lack of control over the CEHRT.

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  • Is it better to report MIPS as an individual or as a group?
  • Your best reporting option, whether as an individual or a group, will depend on your unique practice circumstances. Providers are encouraged to calculate their scores using both options, then report using the option that earns the most points.

    Generally speaking, reporting as an individual (using NPI/TIN combinations) may benefit practices that:

    • Have a mix of high and low performers. Since even the lowest-performing providers can easily meet the three-point benchmark to avoid a penalty in 2017, it makes sense to preserve the incentive potential of high-performing providers by reporting them individually. This is especially true when high-performing providers have high Medicare revenue.
    • Have more exempt providers than eligible providers.
    • Want to customize the selection of quality measures for each provider based on the providers’ strengths and scope of practice.
    • Wish to directly link provider salaries or bonuses to MIPS payment adjustments.
    • Are not able to report as a group using their EHR. While EHRs should theoretically be able to report on the individual and group level, some vendors are currently unable to support group reporting. In those cases, aggregating data for group reporting would require the use of a third-party registry or QCDR, which would increase administrative burden.

    Reporting as a group (using the practice taxpayer identification number) may benefit practices that:

    • Wish to minimize administrative burden. It is easier to monitor and submit one aggregate report than many individual reports.
    • Wish to streamline payments by having one payment adjustment for the practice as a whole, rather than different payment adjustments for each individual provider.
    • Have a mix of provider types, some of whom have limited Quality measures available. Quality measures reported for a group do not have to apply to every provider in the group.
    • Have some providers who cannot meet the Advancing Care Information base measures on their own. The entire group only needs one patient in the numerator for every base measure in order to earn base points.

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  • How do I know if I am a qualifying participant in an Advanced APM?
  • The following APMs have been designated as Advanced APMs for 2017:

    • next Generation ACO Model
    • Medicare Shared Savings Program—Tracks 2 and 3
    • CPC+
    • CEC—Two-sided risk
    • CJR Payment Model—Track 1 (CEHRT)
    • OCM—Two-sided risk

    QPs in these Advanced APMs are providers who participate in an Advanced APM entity that receives 25 percent or more of Medicare Part B payments or sees 20 percent or more of their Medicare patients through the Advanced APM.

    CMS will release initial QP determination status later this year, but recently announced that based on predictive analysis of 2016 claims, they anticipate that approximately 100 percent of eligible clinicians in the following Advanced APMs will be QPs in 2017.

    • Next Generation ACO Model
    • Medicare Shared Savings Program—Tracks 2 and 3
    • CPC+
    • CEC—Two-sided risk

    Predictions were not made for the OCM or CJR.

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  • Do MIPS adjustments include Medicare HMO plans, or only Original (straight) Medicare plans?
  • MIPS adjustments will impact Medicare primary, Medicare secondary, and Railroad Medicare payments only. They will not affect payments through Medicare HMO plans.

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  • How do I choose my Quality measures?
  • Although CMS combined three programs into one, it did not necessarily make it easier to understand what the requirements were for MIPS reporting or if your practice had to report in 2017.

    When CMS decided to combine Meaningful Use, PQRS, and Value-Based Modifiers, it made some changes to those programs overall. It modified what you need to report, how it is scored, and the method by which you will get the required data to CMS.

    If you are not reporting Quality measures in the MIPS program, the following is simply informational. If you are reporting Quality measures in the MIPS program, the following calls out four areas in which you need to focus and understand:

    1. Is your practice able to choose any measures to report for the Quality category?
      • No. The submission method by which you choose to report will dictate which measures you can choose. For example, if you choose to report via claims, you must choose measures that are approved to send via claims. To determine the approved submission method for the measures your practice has selected, download the zip file for the 2017 Quality Benchmarks. Open the Excel Spreadsheet titled MIPS Benchmark Results and review column C (Submission Method) to be sure the measures list the method in which you will submit data. If your practice’s Quality measures will be reported on claims, then all measures must have claims as the submission method.

    2. What are the submission method types?
      • Claims—the practice will report Quality measures by adding codes to claims prior to claims being sent to the payer.
      • Registry/QCDR—the practice will report Quality measures via its EHR’s quality registry or register with a third-party vendor if the EHR vendor does not offer this service.
      • EHR—the practice will report Quality measures through its EHR vendor.
    3. How are the measures scored?
      • Once you narrow down which measures to report and how to submit them, you must look at how many points they are worth. Performance measures will be scored using a decile scoring methodology. Measures that are considered topped out will yield lower values than those that are not topped out.

      • Below is an example for Measure 236—Controlling High Blood Pressure. If the provider(s) report 73% of patients with controlled high blood pressure, they would score 7 points.

      • Measure 236—Controlling High Blood Pressure

        • 3 Points 51.00–58.20 %
        • 4 Points 58.21–63.56 %
        • 5 Points 63.57–68.27 %
        • 6 Points 68.28–72.40 %
        • 7 Points 72.41–76.69 %
        • 8 Points 76.70–82.75 %
        • 9 Points 82.76–91.06 %
        • 10 Points 91.07%
    4. Topped-Out Measures
      • Be mindful when selecting measures that appear to be easy. CMS considers these types of measures topped out.

      • CMS describes a topped-out measure: “A measure may be considered topped out if measure performance is so high and unvarying that meaningful distinctions and improvement in performance can no longer be made.” This means that at least half of the clinicians reporting that measure have a performance rate of 95 percent or higher (5 percent or lower for inverse measures).

    When choosing Quality performance measures, it is critical that you understand methods by which to report, measure placement within deciles, and measure value. Refer to the spreadsheet mentioned above, 2017 MIPS Quality Benchmarks, as a guide when deciding which measures to report. If MACRA or MIPS still seem unclear to you, seek guidance from your EHR vendor or a healthcare consulting firm.

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    • What if I don’t have six quality measures to report?
    • Quality counts for 60 percent of your MIPS Composite score and one bad measure can affect your overall Performance score and determine your incentive payout. You will need to decide on six applicable measures for your practice, including an outcome measure. From the QPP website, “‘Applicable’ is defined as measures relevant to a particular MIPS-eligible clinician’s services or care rendered. MIPS-eligible clinicians can refer to the measures specifications to verify which measures are applicable.”

      To ensure there are enough applicable measures, locate the specialty measure set that most closely aligns with your scope of practice at https://qpp.cms.gov/mips/quality-measures. CMS has determined that the measures in these sets (pulled from the full list of 291 individual measures) are the ones that are generally applicable for each specialty. If the set includes fewer than six applicable measures, the eligible clinician only needs to report on those that apply. Should a specialty measure set contain fewer than six measures, a clinician will meet the minimum reporting requirement by reporting all the measures in the set.

      If a clinician reports fewer than six measures, CMS will use a validation method during the scoring process to determine if the clinician could have submitted additional measures. If CMS determines that there were no other applicable measures to report, the eligible clinician will be scored only on the measures submitted. If CMS determines that the eligible clinician could have submitted additional measures, CMS will assign a score of zero for each non-reported measure. This will result in a lower overall Quality score and MIPS Composite score for the eligible clinician.

      The other option, for those clinicians who have practice partners with more than six applicable measures, is to report as a group. By reassigning your billing rights to the same TIN (tax identification number), all providers of the TIN can submit aggregated quality data as a group. The group’s chosen measures do not have to apply to every provider in the group. Only the providers with applicable data for each measure will be included, but the whole group will receive the same score for the selected measures.

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    • Do I still have to report Medicaid Meaningful Use?
    • You do not need to participate in the Medicaid EHR Incentive Program—otherwise known as Medicaid Meaningful Use (MU)—to avoid a penalty. You only need to participate in the Medicaid EHR Incentive Program if you are still eligible for an incentive payment. Eligible hospitals and professionals that attest directly to a state for the state’s Medicaid EHR Incentive Program will continue to attest to the measures and objectives as finalized in the 2015 EHR Incentive Programs Final Rule (80 FR 62762 through 62955). However, this will not satisfy your requirements to report the Advancing Care Information category of MIPS. Because of the significant differences between MIPS and the Medicaid EHR Incentive Program, especially with Stage 3 in 2018, clinicians seeking a Medicaid MU incentive payment will report separately and independently to their state Medicaid MU program and to the MIPS ACI category.

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    • Do I have to report for a full year to get the maximum incentive?
    • No. A common misconception is that practices are not fully participating and cannot reach the maximum incentive unless they use a full year as their reporting period for 2017 MIPS submission. Full participation in the 2017 MIPS program is defined as reporting for 90 days, for 50 percent of your eligible patients for all payers, and for all three performance categories. Please note the requirement to include data from all payers is a significant change from the PQRS program. When the 2017 Final Rule was published, CMS came up with the less demanding data-completeness criteria of 90 days and 50 percent of patients eligible for the measure. They still encourage reporting data for a full year, but are focusing on rewarding the quality of data, not the quantity. For 2018 and beyond, prepare for an entire-year submission.

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    • Do I have to report all categories using the same reporting method?
    • No. CMS has created flexibility and expanded reporting methods to achieve the greatest participation by clinicians. It is quite feasible that some practices will use three different methods to report the ACI, Quality, and IA categories. The best and most efficient way to report most categories is usually through your EHR. To submit data and report under ACI, an EHR is required. For many of the IAs, you will simply submit an attestation that an activity was done and save the documentation.

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    • If I report in more than one category, do I have to use the same reporting period for all categories?
    • No. You may pick any consecutive 90-day period for Quality or ACI categories, and they do not have to match. In some cases, it may be a good idea to choose the same reporting period as there may be some overlap in the measures. This is particularly true with the ACI performance measures and IA measures where you may get credit in both areas for a single measure. In that case, you would want to use the same consecutive 90 days or risk duplication of your effort. Since you may need to report using different data submission methods for example, you may report quality by means of a registry and then ACI through your EHR. It is perfectly acceptable to pick a different 90-day period and different data submission methods.

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    • What information do I have to report for the Improvement Activities category?
    • When it comes time to report MIPS, you will simply attest to completing the applicable IAs. However, you should set up a binder or Excel spreadsheet with all of the supporting documentation that demonstrates how you comply with the activity in case you are audited at some point. That should include any questions you had for your vendors and answers received by e-mail or any documents they provided you. Each measure will require different documentation. Your EHR or registry vendors may assist you with what to keep on hand or you may contact any of the free technical advisory support organizations by visiting https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf.

      Below is an example of documentation for Improvement Activity ID IA_EPA_1:

      Provide 24/7 access to eligible clinicians or groups who have real-time access to medical records.

      You should include:

      • Documentation that states in an invoice or contract that you have purchased the service from a vendor.
      • Examples of notes documented after hours in patient records.
      • Logs or other records of phone calls and any access to the medical record to review labs or notes that may be demonstrated through medical record audits.
      • Proof of expanding your clinic hours or locations in the community.
      • Documentation in the patient medical record of an emergency department visit or any after-hours prescription(s) sent into a pharmacy.

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    Glossary of Terms

    • ACI: Advancing Care Information

      ACO: accountable care organization

      APM: alternative payment model

      CMS: Center for Medicare and Medicaid Services

      CAHPS®: Consumer Assessment of Healthcare Providers and System

      CEC: Comprehensive ESRD Care

      CEHRT: certified electronic health records technology

      CHIP: Children's Health Insurance Program

      CJR: Comprehensive Care for Joint Replacement

      CMS: Centers for Medicare and Medicaid Services

      CNP: certified nurse practitioner

      CNS: clinical nurse specialist

      CPC+: Comprehensive Primary Care Plus

      CPT®: Current Procedural Terminology

      CRNA: certified registered nurse anesthetist

      DC: doctor of chiropractic

      DDS: doctor of dental surgery

      DMD: doctor of dental medicine

      DO: doctor of osteopathic medicine

      DPM: doctor of podiatric medicine

      EHR: electronic health record

      EPA: Expanded Practice Access

      ERSD: end-stage renal disease

      HMO: health maintenance organization

      IA: Improvement Activities

      MACRA: Medicare Access and CHIP Reauthorization Act

      MD: medical doctor

      MIPS: Merit-Based Incentive Payment System

      MU: Meaningful Use

      NPI: National Provider Identifier

      OCM: Oncology Care Model

      OD: doctor of optometry

      PA: physician assistant

      PQRS: Patient Quality Reporting System

      QCDR: Qualified Clinical Data Registry

      QP: qualifying participant

      QPP: Quality Payment Program

      QRDA: Quality Reporting Document Architecture

      TIN: taxpayer identification number

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The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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