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Measures, MACRA and MIPS explained: What You Need to Know

December 6, 2018


With the consolidation of the Merit Based Incentive Payments System (MIPS) and other quality programs into the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), effectively abolishing the flawed Sustainable Growth Rate (SGR), implementation of these new changes and programs has caused plenty of confusion among various providers. As if staying on top of the latest medical trends while tending to patients isn’t enough of a challenge, tracking the various quality measures and scores is boggling to experts and practitioners alike.

Depending on the specific measures, a practitioner’s base pay may be positively or negatively adjusted. A composite performance score as calculated by the Merit-based Incentive Payments System (MIPS) will determine whether a provider receives positive, neutral or negative adjustments on base pay. Here are a few explanations to clear up some of the confusion:

The purpose of MACRA

The intent of the creators of MACRA was to repeal and replace the flawed Sustainable Growth Rate Formula

Improve ways in which Medicare rewards clinicians for adhering to the goals of value over volume

Streamline the quality reporting process by consolidating multiple quality reporting programs into the Merit-based Incentive Payments System (MIPS)

Offer bonus payments for participation in (eligible) Advanced Alternative Payment Models (APMS).

Key provisions and goals

Recognizing that implementing the new rules has posed time and recording burdens for many practitioners, CMS is committed to introducing quality measures that:

  • Improve patient outcomes
  • Increase value in care levels
  • Minimize reporting  burdens on clinicians

What are the penalties are involved?

As currently written, while providers are not required to participate in the MIPS reporting, they can expect to be paid less for not doing so.  They stand to lose a 4 percent negative adjustment by Medicare at the onset, with the penalty increasing over the years.

Are there any exemptions from reporting data?

Some doctors can be exempt under certain conditions:

  • Those who participate significantly in Advanced Alternative Payment Models (APMS)
  • Those whose income in a given year falls below the volume threshold of submitted charges of less than $90,000 or saw fewer than 200 patients
  • Physicians who are newly-enrolled for the first time during a reporting period

What are the performance categories in which providers submit data?


Providers submit data concerning:

  • Patient outcome
  • Patient safety
  • Care efficiency
  • The appropriate use of medical resources
  • Care coordination
  • The patient’s experience

Under the “Quality” heading, providers need to choose to report six measures that best reflect their practice, with one of these being a cross-cutting measure and another being an outcomes measure.

Improvement Activities

These make up 15 percent of the score, and include practice-enhancing activities such as coordinating care, patient safety, shared decision-making, and increasing patient access to care.

Advancing Care Information

This comprises 25 percent of the total score and has replaced previous EHR Meaningful Use reporting, with clinicians submitting data on information exchange and interoperability.

How are measures reported?

Individual providers can be reported through qualified clinical data registries (QCDRs), qualified registries, claims, as well as with EHRs. Larger medical groups can use QCDRs, EHRs, qualified registries and the web interface for CMS.

Eligible physicians can opt for participation in the Alternative Payment Models (APM) program if eligibility requirements are met. These programs include:

  • CMS Innovation Center initiatives (excluding Health Care Innovation Awards)
  • Medicare Shared Savings Program ACOs
  • Certain CMS-approved demonstration programs

What about those final scores that are coming out?

With the closing of the 2017 submission period back in April 2018, following the evaluation of all submitted data,  providers will be able to access the preliminary as well as final feedback after July 1 via your Enterprise Identity Management credentials (EIDM) that were used to report and review your data during the earlier submission period. 

The data will be available on the Physician Compare website as well as downloadable master files on thousands of MIPS-reporting clinicians. The scores will soon be available for consumer and patient viewing and information on websites such as RateMDs, Vitals and HealthGrades.  Needless to say, providers cannot underestimate the importance of these scores on their reputations.

What’s ahead for 2019

While committed to supporting all practices, CMS will continue to focus on those that are small, independent and or rural. MIPS’ first two years of transition were gradually implemented to allow clinicians to have more time to spend with patients while needing to spend less time meeting regulatory requirements.

Data from that time period will be used to project future eligibility, performance rates, payment adjustments and more.

New reporting guidelines now permit Expanded Participation Options for Year 3, which include:

  • Physical therapist    
  • Occupational therapist
  • Qualified speech-language pathologist
  • Qualified audiologist
  • Clinical psychologist
  • Registered dietician or nutritional professionals

Groups or clinicians may opt-in to MIPS as long as they meet or exceed the CMS guidelines by exceeding at least one but not all of the low-income threshold criteria. For more information see CMS’s Year 3 final rule overview fact sheet.

Additional resources

  • Measure methodology documents for the eight episode-based cost measures, which are finalized for the MIPS category of cost performance in the CY2019 PFS final rule.
  • Measure codes list files contain the codes that specify each of the eight episode-based cost measures for CY2019 PFS final rule.
  • If you’re looking for information about the MIPS 2019 participation year, here’s a handy quick start guide to get started.

How a medical billing service can help

M-Scribe has been in the business of helping practices of all specialties and sizes with billing and practice-management concerns since 2002. Our personnel stay on top of implementing the latest changes to billing and revenue management to ensure that all claims meet the necessary payer criteria, including assistance with the reporting process. M-Scribe offers additional services to further grow your practice with additional streams of income and oversight.

Contact us by email or phone at 770-666-0470 for a confidential consultation to learn more about how we can help you take control over your revenue cycle and increase profitability.


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