The MIPS Survival Guide -...

The Definitive Guide for Surviving the Merit-Based Incentive Payment System

The MIPS Survival Guide

The MIPS Survival Guide

An Introduction to the Merit-Based Incentive Payment System (MIPS)

Survival Tip #1: Know how much your organization needs to participate.

• Clinician Eligibility & Exemptions

• Reporting MIPS as a Group

• MIPS Transition Year Options

Survival Tip #2: Plan your path to data submission.

• Overview of your MIPS Journey

• Quality Performance Category

• Advancing Care Information Performance Category

• Improvement Activities Performance Category

Survival Tip #3: Track your MIPS final score throughout the performance year.

• Performance at a Glance

• Quality Measure Scoring

• Advancing Care Information Scoring

• Improvement Activities

T A B L E O F C O N T E N T S

1

2

3

4

In October of 2016, Department of Health and Human Services (HHS) released the final rule for the MACRA Quality Payment Program. The Quality Payment Program has two tracks: the Merit-Based Incentive Payment

System (MIPS) and Advanced Alternative Payment Models (APMs).

MIPSA n I n t r o d u c t i o n t o

The program updates made in the final rule were

taken directly from stakeholder feedback given

during the comment period for the proposed

rule. Specifically, it addressed improving support

for small and independent practices, expanding

opportunities to participate in Advanced APMs,

and connecting statutory domains into one

unified program that supports clinician-driven

quality improvement. Most notably, it introduced

an iterative and learning period to allow eligible

clinicians to get up to speed with the new

regulations. The performance years of 2017 and

2018 will be considered transition years, and will

feature pacing options that allow providers to

avoid negative payment adjustments with minimal

reporting required.

The bulls-eye for us isn’t what will happen with this program in 2017, it’s about what will lead to the best patient care in the long term.

-Andy SlavittCMS Acting Administrator

of MIPS eligible clinicians report that they are not prepared for MIPS.

64%via HIMSS survey, 2017

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Clinician Eligibility & ExemptionsReporting MIPS as a Group

Pick Your Pace

Survival Tip #1

Know how much your organization needs to

participate.Clinician Eligibility & Exemptions

Reporting MIPS as a GroupPick Your Pace

NEWLY ENROLLED IN MEDICARE

If a clinician enrolls in Medicare at a period of time that does not allow

them to report for a full perfor-mance period, they will be exempt.

LOW-VOLUME THRESHOLD

Eligible clinicians or groups will be exempt from MIPS reporting if they bill ≤ $30,000 or provide care for ≤ 100 Medicare Part B

patients.

ADVANCED APM PARTICIPATION

If an eligible clinician is a part of an Advanced APM, then they are exempt from MIPS reporting. Current exam-ples of APMs are Accountable Care Organizations (ACO), Patient Cen-tered Medical Homes, and bundled

payment models.

Compared to past CMS quality initiatives, the pool of eligible clinicians will be shrinking significantly for the 2017 performance year. However, any clinician that bills Medicare Part B can practice

reporting for MIPS in 2017.

MIPS Eligible CliniciansH o w t o i d e n t i f y

Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists

Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists,

dietitians/nutritional professionals

2017+

2019+

Performance Year MIPS Eligible Clinicians

MIPS Eligibility Exemptions

6

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One of the trickiest aspects of the new CMS Quality Payment Program is understanding how to report MIPS as a group. Group reporting is when a TIN of 2 or more providers decides to report

their measures and activities on the group (TIN) level, rather than on the individual (TIN+NPI) level.

Reporting MIPS as a GroupA g u i d e t o

Reporting as a group can be an advantage to a practice that has a few providers who struggle to find measures that are relevant to them personally, or a practice exercising the “test option” of MIPS reporting for 2017. Whether they chose to report individually or as a group, eligible clinicians must report consistently across all three MIPS performance categories.

Reporting at a TIN level may include clinicians that would otherwise have qualified for an exemption. If reporting individually, clinicians would qualify for exemption if they fall below the low-volume threshold of billing ≤ $30,000 in Medicare Part B charges or providing care for ≤ 100 Medicare Part B beneficiaries. Likewise, clinicians who are newly enrolled in Medicare would be exempt. However, when part of a TIN that is reporting as a group, these clinicians would be included.

For two performance categories, there are some special circumstances that may effect the total number of eligible clinicians or amount of reporting that needs to be completed. However, There are conditions in both Advancing Care Information

and Improvement Activities that could change the requirement for the category, or allow an individual to be entirely exempt.

When reporting individually, both non-physician eligible clinicians and hospital-based clinicians are exempt from the Advancing Care Information Performance Category. Group reporting will include non-physician providers, but still exclude hospital-based clinicians. The ACI hardship exemption would most likely apply to a whole group as well, although if you have an extreme circumstance, we recommend that you contact the QPP help desk to determine whether or not your group will qualify for a hardship exemption.

Rural and non-patient facing clinicians are only required to report 20 points in Improvement Activities to successfully complete the category. Groups reporting Improvement Activities can qualify as non-patient facing groups and therefore subject to the same condition if 75% of the clinicians included in the TIN qualify as non-patient facing. Otherwise, they must report the full amount of Improvement Activities. However, Improvement Activities is an easy category to complete as long as your practice has the correct documentation in place.

Who is included? Who is not included?Clinicians who individually fall below

the low-volume thresholdGroups that as a whole fall below the

low-volume threshold

Clinicians who are newly enrolled in Medicare

Clinicians who do not bill Medicare Part B

QPs/ Partial QPsAudiologists, LCSWs, psychologists, & others that are not eligible until 2019

Improvement Activities

Advancing Care Information

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To ease the burden of transitioning to MACRA, CMS has introduced three pacing options for the performance year of 2017. The 2017 MIPS performance threshold will be three (3) points. As long as

an eligible clinician or group meets this threshold, no penalty will be attributed to their2019 billing.

Don’t Participate0 points

-4% Penalty

Test Participation3 points

No Adjustment

Partial Participation4-69 points

0% to 3.9% Incentive

Full Participation70-100 points

+4% to +22% Incentive

Full ParticipationEligible clinicians who completely report to all three weighted performance categories will be eligible for a

moderate positive payment adjustment. To review, complete reporting requires:

• Quality: Six measures covering 50% of eligible patient visits

• Advancing Care Information: Attesting to all base measures, and accumulating some performance

score and / or bonus points.

• Improvement Activities: 40 points achieved

Partial ParticipationEligible Clinicians who submit “more than minimal” data for any of the three categories for at least 90 days

will be eligible for a slight positive payment adjustment. Longer reporting periods will be more likely to

result in higher incentives, as will reporting to the full requirements of each performance category.

Minimal ParticipationMinimal reporting for MIPS is considered to be either:

• One measure from the Quality Performance Category

• One activity from the Improvement Activities Category -OR-

• All base measures from the Advancing Care Information (ACI) Category

Failing to successfully complete any one of these options will result in a negative 4% payment adjustment.

Pick Your Pace in 2017M I P S T r a n s i t i o n Y e a r O p t i o n s :

- Seema Verma, Administrator for CMS


“MACRA was an important step

forward to provide stability for

providers and move us toward

better outcomes. The most

important thing we can do is

engage stakeholders not just on

the front end, but all the way

through. What are they going

through and what are their

challenges?”

Survival Tip #2

Plan your path to data submission

Overview of Your MIPS Journey

Quality Measures


Performance Category


An eligible clinician will have their MIPS performance measured through three connected categories. The Composite Performance Score (CPS) will be aggregated from the following performance categories: 60% Quality (previously PQRS) , 25% Advancing Care Information (previously Meaningful Use), and 15% Improvement Activities. If Advancing Care Information does not apply to a clinician or organization, the 25% will be reallocated to Quality,

adjusting the weight for that category to 85%.

Your MIPS JourneyA n O v e r v i e w o f

0%Cost

15%


25%

Advancing CareInformation

(ACI)

60%

Quality


60%of MIPS SCORE

The MIPS Quality Performance Category is closely related to its predecessor, the Physician Quality Reporting System (PQRS).

Quality Measures

Select Measures• Determine level of participation

• Report 1 Quality Measure to avoid the MIPS penalty, or report up to 6 quality

measures to get an incentive payment.

• Select at least 1 outcome measure

• If no outcome measure is applicable, report at least 1 high-priority measure.

• Select the rest of the measures you plan to report

• Bonus points will be awarded for selecting outcome or high-priority measures.

• Selecting more than 6 measures can be a good idea. At the end of the year, CMS will

accept the highest performing measures and disregard the rest!

1

Review DataYour MIPS Quality Performance Category score will be determined based on

benchmarks obtained from a prior year. MIPSPRO features a dashboard

integrated with these benchmarks. Start early to monitor and achieve

a maximized score!

3

Record Quality Measure Data• Determine reporting period

• Your reporting period in 2017 must be at least 90 consecutive days between

January 1, 2017 and December 31, 2017.

• 50% the eligible instances across all payers must be reported for the allotted

time period.

• For the best chance at an incentive, the entire year must be reported.

2



25%of MIPS SCORE

The Advancing Care Information (ACI) Performance Category is Meaningful Use updated to be more flexible, customizable, and focused on patient engagement and interoperability. ACI is worth 25% of your MIPS Composite Performance Score.

Determine ACI EligibilityExempt clinicians and groups will have ACI re-weighted to 0% and Quality re-

weighted to 85% of their MIPS score. Valid exemptions include:

• Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists,

Certified Registered Nurse Anesthetists

• Hospital-based clinicians

• Non-patient facing clinicians

• Clinicians who qualify for a hardship exemption

4

Performance ScoreIn addition to the required measures,

you can report other ACI measures

to receive full credit for the ACI

performance category. In order

to receive credit towards your

performance score, you must

report numerator and denominator

information for measures, instead of

simply attesting.

The total ACI Performance Category

score will be capped at 100 points,

so you only need 50 performance

score points to have a perfect score

for the Advancing Care Information

Performance Category.

7

Select MeasuresDetermine if your EHR is certified to

the 2014 or 2015 edition. This will

determine the set of measures you

are eligible to use.

5

Review Data• Participation in an additional public health & clinical data

registry is worth 5 extra ACI Performance Category points

• Reporting certain Improvement Activities through

CEHRT is worth 10 extra ACI Performance

Category points

8

Base Score Measures6Attesting at least to the base measures is required to

receive any credit for ACI.

Reporting the required base measures will award you 50

points out of the possible 100 category points. To avoid

the negative MIPS payment adjustment, this is all that is

required. To receive a positive payment adjustment, you

will need to also report performance score measures.


The Improvement Activities Performance Category is a new concept introduced by MIPS reporting that rewards eligible clinicians for participating in activities related to their patient population. Eligible clinicians can select from 92 different activities to earn credit, all designed to improve quality of care. The Improvement Activities Performance Category is worth 15% of the MIPS Composite Performance Score in 2017.

The standard number of required points and the maximum score for this Performance Category.

For small or rural practices, HPSAs, or non-patient facing clinicians/groups.

+20POINTS

+10POINTS

+20POINTS

AUTOMATICALLY

HIGH-WEIGHTED ACTIVITIES

MEDIUM-WEIGHTED ACTIVITIES

ALTERNATIVEPAYMENTMODELS

Certified Patient Centered Medical Homes receive full credit automatically.

The minimum point requirement, which result in no penalty or incentive.

40POINTS

20POINTS

0POINTS

10POINTS

15%of MIPS SCORE

Select from 92 activities to achieve the desired level of credit

10

SUBMIT!11

Determine how many points are needed for successful reporting

9


Survival Tip #3Track your MIPS final score

while you report

Performance at a Glance

Scoring Quality Measures

Scoring Advancing Care Information

Scoring Improvement Activities


Performance Category ScoresAll performance categories have are scored

individually and add up to your MIPS final

score. For 2017 performance, Quality and

ACI will have scores posted publicly.

Payment Adjustment ScheduleIn 2017, penalty for non-reporting is -4%.

Exceptional performance can boost your

incentive up to 22%. Incentives and penalties

will increase with time.

MIPS Final ScoreYour MIPS Final Score will be publicly

available on Physician Compare and will

determine your payment adjustment.

Physician CompareThere will be a 30-day preview period to

contest publicly available performance

scores. Performance will then be available

to the public.

2017 2018 2019 2020

Why does MIPS performance matter? With revenue and your reputation on the line, there are several factors that you will want to consider when determining your level of MIPS reporting.

Performance at a Glance U n d e r s t a n d i n g M I P S



How CMS will Score MIPS Quality Measures

The MIPS Quality Performance Category is replacing PQRS reporting in 2017, folding it

into the Merit-Based Incentive Payment System. The Quality portion will comprise 60%

of an eligible clinician’s MIPS Composite Performance Score for 2017. To calculate that

score, there is significant math involved. This article will walk you through the calculations

and logic used to determine your Quality score, but it is important to note that many data

submission vendors will automatically give you a predictive calculation.

1. Decile DeterminationEach previously utilized measure has been reviewed for benchmarks

from data gathered from a prior performance period. CMS has

gathered that data and analyzed it in terms of reliability. If a measure

has sufficient data, CMS has determined deciles based on that data.

2. Points per DecileFor each individual clinician or group, points will be awarded for

each measure with at least 20 cases submitted based on where the

provider’s performance score falls. The decile a provider falls into will

be the score they receive for that measure. For example, a measure

the performs in the 9th decile will receive 9 points. If the provider

has less than 20 cases, 3 points will be awarded. It is important to

note that for the 2017 performance period, zero points will only be

awarded for a measure if it is not reported at all.

3. Measures with No BenchmarksFor measures with no historic benchmark, CMS will attempt to

calculate benchmarks based on 2017 performance data after

data is submitted. Benchmarks are created if there are at least 20

reporting clinicians or groups that meet the criteria for contributing

to the benchmark, including meeting the minimum case size (which is

generally 20 patients), meeting the data completeness criteria, and

having performance greater than 0 percent (less than 100 percent for

inverse measures). If no historic benchmark exists and no benchmark

can be calculated, then the measure will receive 3 points.

4. More than Six MeasuresIf more than six measures are submitted, CMS will use the top six

measures’ scores. This gives providers an opportunity to over-

report without worrying about damaging their MIPS Composite

Performance Score, and actually providing incentive to track more

than the minimum required number of measures.

5. Bonus PointsThe Quality Performance Category offers options for increasing a

provider’s score. Bonus points can be earned by submitting extra

outcome or high priority measures (2 points for each additional

outcome measure and 1 point for each additional high priority

measure). In addition, if the provider submits data via end-to-end

electronic technology, an additional 1 point per measure will be

awarded (up to 10 percent).

6. A Potential Additional MeasureIf a practice is comprised of 16 or more eligible providers, CMS

will calculate the All-Cause Hospital Readmission measure from

the claims submitted for the year. This calculation is then added

to the calculations for the MIPS Advancing Care Information and

Improvement Activities component to determine the final MIPS

score. Once the MIPS score is determined, it will be compared to the

other MIPS scores achieved during the year and a reimbursement

adjustment will be determined.


Decile DeterminationEach previously utilized measure has been reviewed for

benchmarks from data gathered from a prior performance

period. CMS has gathered that data and analyzed it in

terms of reliability. If a measure has sufficient data, CMS

has determined deciles based on that data.

Points per DecilePoints will be awarded for each measure with at least 20

cases submitted based on where the performance score

falls. The decile will determine the points received for a

measure. Zero points will only be awarded for a measure

if it is not reported at all.

Measures with No BenchmarksFor measures with no historic benchmark, CMS will

attempt to calculate benchmarks based on 2017

performance data after data is submitted. If no historic

benchmark exists and no benchmark can be calculated,

the measure will receive 3 points.

Bonus PointsThe Quality Performance Category offers options

for increasing a provider’s score. Bonus points can be

earned by submitting extra outcome or high priority

measures (2 points for each additional outcome

measure and 1 point for each additional high priority

measure). In addition, if the provider submits data via

end-to-end electronic technology, an additional 1 point

per measure will be awarded (up to 10 percent).

All-Cause Hospital ReadmissionIn certain cases, a seventh measure will be

automatically reported. If a practice is comprised of 16

or more eligible clinicians, CMS will calculate the All-

Cause Hospital Readmission measure from the claims

submitted for the year. Although there will now be 70

possible category points, the Quality category will still

account for 60% of the MIPS final score.

Scoring Quality Measures

Measure Bonus Points

Bonus points cap at 10% of

possible score. 1 point is gained

per additional high-priority

measure; 2 points per outcome

measure.

6 points

+CEHRT

Bonus Points

For each measure that is reported

end-to-end through CEHRT, a

bonus point will be awarded.

Bonus points are capped at 10%

of total possible category score.

6 points

Total Category Score

Add up all your points and

divide them by the total possible

category points. The resulting

percentage is your Quality

category score (max 100%).

0 - 60%

=Measure

Decile Points

0 points only awarded for not

reporting a measure. Reported

measures will be converted into

deciles and scored out of 10

possible points.

0 -60 points

+

Quality will comprise 60% of an eligible clinician’s MIPS Composite Performance Score for 2017.

To calculate that score, you must first understand how each measure is scored, available bonus

points, and any special circumstances that may apply.



Scoring the MIPS Advancing Care Information (ACI)

Performance Category in 2017Advancing Care Information aims to measure how effectively clinicians are utilizing their

Certified EHR Technology. The Advancing Care Information performance score will be

calculated using a combination of attestation and performance.

1. Base ScoreThe base score is worth 50% of the Advancing Care Information Performance Category Score (50 points). To receive the full base score, an eligible clinician must at minimum attest to the required Advancing Care Information Measures. The required measures will vary based on the certification edition of your EHR.

To be awarded any credit for the Advancing Care Information Performance Category, the quality action for each required measure must be met at least one time. If you do not meet that requirement for any required measure, you will score 0 points for the Advancing Care Information Performance Category.

2. Performance Score

In order to receive any performance score points, the base score measures must be attested to. Although the base score is awarded through a simple attestation, the performance score (as the name implies) is awarded based on your performance on certain measures. You can determine the maximum possible performance score points for a measure by looking at the "Performance Score Weight" section of the ACI measure specifications.

Predicting your performance score is straightforward. Your performance rate, or the number of times you complete the specified quality action for a measure compared to the total number of times you reported the measure, will directly relate to the performance score you receive. You can receive a maximum of 90 points in the performance score category. The total category score will be capped at 100%, so you only need 50% as a performance score to have a perfect score for the Advancing Care Information Performance Category.

3. Bonus PointsBonus points are available through reporting to one or more public health and clinical data reg-istries beyond the Immunization Registry Measure (+5%), or by reporting specified Improve-ment Activities (+10%). In total, eligible clinicians can receive up to a 15% bonus score.

Measure Name CEHRT Edition

e-Prescribing

Provide Patient Access

Security Risk Analysis

Health Information Exchange

Request/Accept Summary of Care

Send a Summary of Care

2014 & 2015

2014 & 2015

2014 & 2015

2014

2015

2015

Base Score

PerformanceScore

Bonus Points

PerformanceCategory

Full credit awarded for provid-

ing numerator / denominator

information or yes/no answers

for each measure and objective.

Percentage of patients with a

met performance on specified

measures aimed at emphasiz-

ing patient care and informa-

tion access.

Report to additional public

health & clinical data registries

beyond the Immunization

Registry Reporting measure

(5 points) and/or report IA

through CEHRT (10 points)

Scoring 100 points or higher in

the ACI Performance Category

counts as full credit for the ACI

portion of the MIPS CPS (25%)

50 points Up to 90 points Up to 15 points ≤100 points+ + =



Improvement Activities Scoring

Improvement Activities is the simplest category to score. Each activity is assigned a

weight, either medium or high. Medium-weight activities are worth 10 points, while

high-weight activities are worth 20 points. Most practices will need 40 total points to

receive full credit in this performance category.

Small Practices (less than 15) or HPSAs

(Healthcare Professional Shortage Areas)

are only required to report 20 points.

Participation in an Alternative Payment

model is already worth 20 points, so only

20 additional points would be needed.

Exceptions:

The Improvement Activities Performance Category is worth 15% of your total MIPS

score, which means that successfully attesting to the activities you have completed will

award you anywhere between 3% and 15% of your final MIPS score.

Total Activity Points

Full credit awarded for providing

numerator / denominator

information or yes/no answers for

each measure and objective.

0-10 points

+Total Possible

Points

Percentage of patients with a

met performance on specified

measures aimed at emphasizing

patient care and information

access.

40 points

PerformanceCategory Score

If you take this percentage, and

multiply it by 15% you will get

the final points earned for the IA

portion of the MIPS CPS in 2017.

0 - 100%

=


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