Quality Reporting

MIPS AND QUALITY REPORTING

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What is MACRA and MIPS?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law by President Obama on April 16, 2015.

MACRA created the Quality Payment Program that:

  • Repeals the Sustainable Growth Rate formula
  • Changes the way that Medicare rewards clinicians for value over volume
  • Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
  • Gives bonus payments for participation in eligible alternative payment models (APMs)

The program is focused on quality, value, cost, and accountability.

The eligible clinicians have two tracks to choose from in the Quality Payment Program based on their practice size, specialty, location, or patient population:

Quality Payment Program
Merit-based Incentive Payment System
Advanced Alternative Payment Models

Merit-based Incentive Payment System (MIPS)

Advanced Alternative Payment Models

What is MIPS?

MIPS is one of the two new payment tracks under Quality Payment Program where you earn a performance-based adjustment to your Medicare payment.

MACRA combines several programs, previously known as 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, with additional of two new components called Improvement Activities and Cost. Using a composite performance score, eligible professionals (EPs) may receive a payment bonus, a payment penalty, or no payment adjustment.

Quality

Quality

Improvement Activities (IA)

Improvement Activities (IA)

Cost

Cost (VBM)

Promoting Interoperability (PI)

Promoting Interoperability (PI)

MIPS Eligibility

Your eligibility is based on your:

  • National Provider Identifier (NPI) and
  • Associated Taxpayer Identification Numbers (TINs).
A TIN can belong to:

  • You, if you’re self-employed,
  • A practice, or
  • An organization like a hospital.

When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination.
If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations.

Each TIN/NPI combination is evaluated for MIPS eligibility. We’ll use TINs to evaluate practices for eligibility.

Check Your Eligibility

MIPS Eligible Clinician Types

You are eligible to report for MIPS if you are a MIPS eligible clinician type. If you’re not one of these, you’re exempted from reporting.

  • Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
  • Osteopathic practitioners
  • Chiropractors
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians or nutrition professionals

MIPS Eligibility: INDIVIDUAL

In order to be MIPS eligible as part of a group, you must:

  • Not be a Qualifying Alternative Payment Model Participant (QP), and
  • Exceed the low-volume threshold as an individual.

If you’re MIPS eligible as an individual, you’re required to report for MIPS.

MIPS Eligibility: GROUP

In order to be MIPS eligible as part of a group, you must:

If you’re MIPS eligible in your group, you’ll receive a score and payment adjustment based on group reporting when the group reports.

Who is Exempted?

Qualifying APM participants, providers with minimum volume threshold of patients or payments,or providers in their first enrollment year with Medicare Part B.

What determines my final MIPS score?

Under MIPS, eligible clinicians (ECs) will be scored annually in four performance categories to derive a MIPS composite score between 0 and 100.A clinician can choose to participate as an individual or in a group for each NPI/TIN combination that they bill under. CMS will apply the payment adjustment at the individual TIN/NPI level for individual submissions and at the practice level for group submissions.

The maximum Composite Performance Score (CPS) is 100 points and is based on four performance categories:

CPS-1
CPS-3
CPS-2
CPS-4

An inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and provides increased access to care.

  • Complex Patient Bonus (if applicable)
  • Small Practice Bonus (if applicable)
Final-Score
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Step-2
Step-3
Step-4
Step-5

The points provided for each category will shift over time.

These four performance categories make up the MIPS final score which is used for determining payment adjustments. The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must typically report their data in the early part of the following calendar year to avoid a payment reduction.

Explore Measure and Activities

This QPP tool has been created to help you get familiar withthe available measures and activities for each performance category under traditional MIPS. It’s for planning purposes only and will not submit anything to CMS. To get the most out of the tool, follow the QPP link here.

See the Full MIPS Timeline

Performance Categories

MACRA

MIPS Quality Reporting Steps

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MIPS-step-2
MIPS-step-3
MIPS-step-4
MIPS-step-5

Fee for Service to pay for Performance

Performance

MIPS 2021 Specifications

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AND

AND

mips-quality-steps-90000

More than $90,000 annually for Medicare

mips-quality-steps-more-200

More than 200 Medicare patients a year

mips-quality-steps-provide-200

Provide 200 or more covered professional services to Medicare Patients

2021

  • Cost 20% 20%
  • IA 15% 15%
  • PI 25% 25%
  • Quality 40% 40%

2022

  • Cost 30% 30%
  • IA 15% 15%
  • PI 25% 25%
  • Quality 30% 30%

Quality

Management

Category is Worth

40% of total MIPS score (reduced from 45% in 2020)

Performance Period

365 Days

Requirements
  • Total of six Quality measures to CMS.
  • At least 1 Outcome measure OR at least 1 High Priority measure.
Important

The data completeness threshold is 70%. This means Quality measures will need to be reported on at least 70% of eligible cases, for both Medicare and non-Medicare patients, for the entire year.

Clinicians in small practices (15 or less in the TIN) would continue to receive 3 points for measures that don’t meet the data completeness requirements.

Case Minimum

Quality measures must meet the 20-case minimum to be scored.

Data Completeness

Measures must contain at least 70% of all Eligible Clinician patients across all payers.

Requirements

You must use EHR technology certified to the 2015 of CEHRT.

You must report all required measures and additional bonus measures to reach full earning potential for this category.

Promoting

Interoperability Category (PI)

Worth

25% of total MIPS score

Performance Period

90 days (minimum)

Improvement

Activities (IA)

Maximum Points: 40 points

2 HIGH weighted activities

Worth: 15% of total MIPS score

1 HIGH & 2 Medium weighted activities

Performance Period: 90 days (minimum)

365 Days

Group Submissions

If you are submitting as a group, at least 50% of your group’s clinicians must attest to completing the same improvement activity for 90 consecutive days. The activity may be completed anytime within the calendar year so long as each person attesting completes the activity for 90 consecutive days.

Patient Centered Medical Homes

If you are a Patient-Centered Medical Home and more than 50% of your practices are recognized as a PCMH, you automatically receive full credit for this category.

Requirements

CMS will calculate cost measure performance; no action is required from clinicians.

Cost

Worth

20% of total MIPS score (Up from 15% in 2020)

Performance Period

365 days

Performance Threshold 2021

Performance Threshold

Performance threshold to Avoid Penalty is INCREASED from 45 to 60.

Performance threshold to Avoid Penalty is INCREASED from 45 to 60.

Exceptional Performer Threshold

No Change – 85.

Payment Adjustment

performance2021

Where do I register for MIPS attestation?

You can sign into your QPP account after you are ready with your MIPS scorecard from your current EHR and PM system.

Alternative Payment Model (APM)

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

Types of APMs

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. There are five different types of APMs:

APMs

Meet the statutory definition of an APM. MIPS eligible clinicians participating in an APM are also subject to MIPS.

MIPS APMs

MIPS APMs have MIPS eligible clinicians participating in the APM on their CMS-approved participation list.

Advanced APMs

An Advanced APM is a track of the Quality Payment Program that offers a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you are excluded from the MIPS reporting requirements and payment adjustment.

Advanced & MIPS APMs

Most Advanced APMs are also MIPS APMs. MIPS Eligible clinicians participating in Advanced APMs are included in MIPS if they do not meet the threshold for payments or patients sufficient to become a Qualifying APM Participant (QP). The MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.

All-Payer/Other-Payer Option

Starting in Performance Year 2019, eligible clinicians will be able to become Qualifying Alternative Payment Model Participants (QPs) through the All-Payer Option. To attain this Option, eligible clinicians must participate in a combination of Advanced APMs with Medicare and Other-Payer Advanced APMs. Other-Payer Advanced APMs are non-Medicare payment arrangements that meet criteria that are similar to Advanced APMs under Medicare.

Source: Centers for Medicare and Medicaid Services APMs Overview

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