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MIPS reporting: Getting off on the right foot

A physician who did not report performance on quality measures to the Physician Quality Reporting System (PQRS) for 2015 now faces a 6 percent penalty on all Medicare Part B payments. The same penalty will apply in 2018 for physicians who do not report performance for 2016.

In addition to PQRS penalties, a 3 percent penalty is now assessed against physicians who did not attest to meaningful use of an electronic health record (MU) for 2015. Again, the 3 percent MU penalty will apply in 2018 for physicians who did not attest for 2016. 

For 2017, new reporting requirements under the Merit-Based Incentive Payment System (MIPS) will take the place of PQRS reporting and MU attestation. If a physician elects not to report any data under MIPS for 2017, they will be subject to a 4 percent penalty on all Medicare Part B payments in 2019. 

For a physician who did not report performance to PQRS and did not attest to MU for 2016 – and thus faces a 9 percent penalty in 2018 – failure to report any data under MIPS for 2017 will mean a 4 percent penalty in 2019. In effect, MIPS means a 5 percent increase in Medicare Part B payments for this physician.

When it comes to quality reporting, failing to submit data can be costly. However, this year, you can start the MIPS transition process off on the right foot. The Centers for Medicare & Medicaid Services (CMS) created the “Pick Your Pace” program to assist physicians in transitioning to MIPS for 2017. A physician (either individually or as part of a group) can avoid the 4 percent penalty in 2019 simply by submitting data relating to a single quality measure or attesting to performing a single clinical practice improvement activity. Physicians who have successfully reported on their performance to PQRS and/or attested to MU previously have the option to not only avoid penalties, but pursue bonus payments as well. 

Reporting on quality measures

To successfully report on a quality measure for 2017, a physician must report data for a continuous 90-day period for a minimum of 20 patients, which must comprise at least 50 percent of the denominator-eligible patients. For example, if a physician were to elect to report on the quality measure for controlling high blood pressure, he or she would report the percentage of patients age 18-85 with a diagnosis of hypertension whose blood pressure is controlled during the measurement period.

Specifically, the denominator would include patients seen by the physician (or, in the case of group reporting, by the group as a whole) within the selected 90-day performance period who are 18-85 years of age with a diagnosis of hypertension. The numerator would be those patients whose systolic blood pressure is below 140 mmHg and diastolic blood pressure is above 90 mmHg at the most recent visit during that period. Again, to be reportable, the denominator would have to include at least 20 patients representing at least one-half of the hypertensive adults seen during the performance period.

A complete list of the 271 approved MIPS quality measures, which includes the definition of the denominator and numerator for each measure, is available on the Quality Payment Program website. The QPP website also provides information on the different ways in which a physician or group can report on the measures (e.g., claims, EHR, registry) and the applicable benchmarks for each measure.

Reporting on clinical practice improvement activities

A physician seeking to avoid the 4 percent penalty in 2019 may elect to report on a clinical practice improvement activity instead of a quality measure. In that case, the physician (either individually or as part of a group) would attest to having engaged in one approved activity for at least 90 continuous days during 2017. The activity does not have to be “new;” a physician can take credit for established programs.

The complete list of the 92 activities approved for 2017 also is available on the Quality Payment Program website. The listed activities cover a broad spectrum, from implementing an antibiotic stewardship program to providing ambulatory care management services. The website also provides information on reporting mechanisms.    

Another option: The advancing care improvement component

A third option for a physician seeking to avoid the 4 percent penalty is successfully reporting on all of the measures included in the base score for the advancing care improvement (ACI) component, which replaces the MU program for physicians. For 2017, the base score measures include: 

    (1) Conducting a security risk analysis

    (2) e-Prescribing

    (3) Providing patient electronic access

    (4) Sending a summary of care

    (5) Requesting and accepting a summary of care 

The first measure requires a “yes” response, while the other four are reported with a denominator and a numerator of at least one. Because reporting a single quality measure or a single clinical practice improvement activity involves less tracking and compilation of data, we anticipate few physicians will use the ACI route to avoid the 2019 penalty.   

Picking up the pace: Pursuing MIPS bonus payments

If a physician has successfully reported performance to PQRS and/or attested to MU in prior years, they may be ready to “pick up the pace” by pursuing MIPS bonus payments. To be eligible for bonus payments, a physician must:

    (1) Report on six MIPS quality measures (unless reporting through the GPRO web interface or through a qualified clinical data registry)

    (2) Attest to having engaged in four clinical practice improvement activities (or only two activities, if certain conditions are satisfied)


    (3) Report on both the ACI base score and performance score measures

If a physician participates in an accountable care organization (ACO) enrolled in Track 1 of the Medicare Shared Savings Program (MSSP), their MIPS reporting requirements are reduced significantly. These physicians only report on the ACI base score and performance score measures; the balance of the MIPS score is based on MSSP performance. 

Physicians who elect to report individually using Part B claims will need to include specified codes on those claims at the time of submission for at least a 90-day period during 2017; one cannot add this information to claims at a later time. Groups with 25 or more practitioners that elect to report through the GPRO web interface must register by the end of June 2017.  Otherwise, physicians will report on 2017 performance during the first quarter of 2018. Now is the time, however, to develop your MIPS game plan, including “pick your pace,” measures selection, and process improvement to improve performance on selected measures.   

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