MIPS - quality measure reporting

Meet MIPS Optimize Medicare Reimbursements

CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).


Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.


Performance is measured through the data clinicians report in four areas - Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. We designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM)We can help clarify a path to meeting MIPS quality reporting guidelines. 

Providers are penalized upto 5% by not meeting them and rewarded upto 10% for exceeding them that is a 15% swing in reimbursements.

  • Which Quality measures apply to A PCP?
  • Which codes carry the most weight?
  • Who is submitting and reporting my codes?
  • What can I monitoring my MIPS reporting status monthly?


read more about this below.

mips for primary care - cms# - CPT cod - Q# - Measure type

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Who Can perform each procedure to meet MIPS

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Notice the Measures that can only be met by the Provider vs RN or LPN

Guidelines for Mips compliance

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MIPS Overview

What

CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.

Performance is measured through the data clinicians report in four areas - Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. We designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).

How it Works

There are four performance categories that make up your final score. Your final score determines what your payment adjustment will be. These categories are:

Quality

This performance category replaces PQRS. This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups. You pick the six measures of performance that best fit your practice.


Promoting Interoperability (PI)

CMS is re-naming the Advancing Care Information performance category to Promoting Interoperability (PI) to focus on patient engagement and the electronic exchange of health information using certified electronic health record technology (CEHRT). This performance category replaced the Medicare EHR Incentive Program for EPs, commonly known as Meaningful Use. This is done by proactively sharing information with other clinicians or the patient in a comprehensive manner. This may include: sharing test results, visit summaries, and therapeutic plans with the patient and other facilities to coordinate care.


Improvement Activities

This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you choose the activities appropriate to your practice from categories such as, enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.


Cost

This performance category replaces the VBM. The cost of the care you provide will be calculated by CMS based on your Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. Beginning in 2018, this performance category will count towards your MIPS final score.

Why

MIPS was designed to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.

When

The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must report data collected during one calendar year by March 31 of the following calendar year. For example, program participants who collected data in 2017 must report their data by March 31, 2018 to be eligible for a payment increase and to avoid a payment reduction in 2019.

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MIPS Alternative Payment Models (APMs)

Certain Alternative Payment Models (APMs) include Merit-Based Incentive Payment System (MIPS) eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. These types of APMs are called MIPS APMs, and participants receive special MIPS scoring under the APM scoring standard. All eligible clinicians should check their participation status to understand their MIPS participation.

MIPS APMs are APMs that meet these 3 criteria:

  • APM entities that participate in the APM under an agreement with CMS;
  • APM entities that include 1 or more MIPS eligible clinicians on a Participation List
  • APM bases payment incentives on performance (either at the APM entity or eligible clinician level), on cost/utilization, and quality measures.

PY 2017PY 2018PY 2019

2018 MIPS APMs

Low Volume Threshold

For ECs participating in MIPS APMs, the Low Volume Threshold (LVT) is calculated at the APM entity level, also referred to as the ACO level.

UPDATEDThis means that even if a clinician or group is at or below the low volume threshold of $90,000 in covered professional services under the Medicare PFS, or furnishing covered professional services to less than or equal to 200 beneficiaries, if they participate in a MIPS APM, they will be subject to MIPS if the APM Entity exceeds the low volume threshold.

Performance Period

The APM scoring standard performance period is the same as the regular 12-month MIPS performance period. Your MIPS payment adjustment in 2020 is based on your 2018 performance under the APM scoring standard.

Snapshots

If you are a MIPS eligible clinician participating in a MIPS APM, then you’re subject to the APM scoring standard. The weights assigned to the MIPS performance categories under the APM scoring standard might be different from the regular MIPS performance category weights. CMS will apply the APM scoring standard using each MIPS APM entity's Participation List at 3 “snapshot” dates: March 31, June 30, or August 31.

If you participate in a MIPS APM but aren’t on the APM Participation List on 1 of the 3 snapshot dates, you won’t be scored using the APM scoring standard and should instead report to MIPS, either as an individual or as a group.

UPDATEDIf an eligible clinician joined a full TIN APM (Medicare Shared Savings Program) after the third snapshot (August 31st), we will use a fourth snapshot (December 31st ) to determine APM participation. The eligible clinicians captured in the fourth snapshot will be scored under the APM Scoring Standard.

Please note that the fourth snapshot is not part of the Qualifying APM Participant (QP) snapshot dates.

APM Scoring Standard

The APM Scoring Standard accounts for activities already required by the APM to reduce duplication of reporting and allow clinicians to focus on the goals of the APM. Therefore, the MIPS performance category weighting and reporting requirements are different than the general MIPS scoring standard.

Advanced APM and MIPS APM eligible clinicians under an entity that are not Qualifying APM Participants (QPs) or Partial Qualifying APM Participants (Partial QPs) are scored under the APM Scoring Standard.

UPDATEDThe performance category weights used to calculate the MIPS final score under the APM Scoring Standard for the 2018 performance period are as follows:

  1. Quality: 50 percent
  2. Improvement activities: 20 percent
  3. ACI: 30 percent
  4. Cost: 0 percent

Learn more about the APM scoring standard:

UPDATEDParticipation

To prepare to participate, you can receive further support with our technical assistance resources.

Join

  1. Learn about specific MIPS APMs and how to apply.
  2. Apply to a MIPS APM that fits your practice and is currently accepting applications.

Current Participants

If you are an eligible clinician currently participating in a MIPS APM (see MIPS APM List), please contact your APM entity for participation specifics.

2018 MIPS APMs

MIPS APMOverviewUPDATEDBundled Payments for Care Improvement Advanced Model (BPCI Advanced)The Bundled Payments for Care Improvement (BPCI) initiative is comprised of 4 broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care.Comprehensive ESRD Care (CEC) Model (LDO arrangement)The Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD).Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)The Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD).Comprehensive ESRD Care (CEC) Model (non-LDO one-sided risk arrangement)The Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD).Comprehensive Primary Care Plus (CPC+) ModelComprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.UPDATEDMedicare Accountable Care Organization (ACO) Track 1+ ModelThe Medicare ACO Track 1+ is a time-limited model for Track 1 Medicare Shared Savings Program (Shared Savings Program) ACOs. The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to provide coordinated, high-quality care to their Medicare patients. Track 1+ Model ACOs assume limited downside risk (less than Track 2 or Track 3).Medicare Shared Savings Program Accountable Care Organizations – Track 1, 2, 3The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to provide coordinated, high-quality care to their Medicare patients. ACOs may participate in the Shared Savings Program under Tracks 1, 2, or 3. Each track varies by their financial risk and portion of savings.Next Generation ACO ModelBuilding upon experience from the Pioneer ACO Model and the Shared Savings Program, the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.Oncology Care Model (OCM) (one-sided Risk Arrangement)Under the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patientsOncology Care Model (OCM) (two-sided Risk Arrangement)Under the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patientsUPDATEDVermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)The Vermont All-Payer Accountable Care Organization (ACO) Model is the Centers for Medicare & Medicaid Services’ (CMS) new test of an alternative payment model in which the most significant payers throughout the entire state – Medicare, Medicaid, and commercial health care payers – incentivize health care value and quality, with a focus on health outcomes, under the same payment structure for the majority of providers throughout the state’s care delivery system and transform health care for the entire state and its population. 

 

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2018 Advanced APMs

Qualifying APM Participant (QP)

APMs allow eligible clinicians to become a QP for an opportunity to receive a 5 percent APM incentive payment and to be excluded from MIPS.

To become a QP, you must meet or exceed 25 percent payments for professional services or 20 percent patients delivered professional services through an Advanced APM entity at one of the determination periods (snapshots).

In addition, 50 percent of practices need to be using certified EHR Technology within the Advanced APM entity.

An APM entity is an group (TIN) that has billing rights of a participant or participants (NPIs) that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation.

In some APMs, the APM entity is an Accountable Care Organization (ACO). ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.

Eligible clinicians may also become a QP through the "All-Payer and Other-Payer Option," which is a combination of Medicare and non-Medicare payer arrangements such as private payers and Medicaid.

Partial Qualifying APM Participant (Partial QP)

All clinicians who participate in Advanced APMs and become Partial QPs may choose whether or not they want to participate in MIPS. If these clinicians choose to participate, they must meet all MIPS reporting and scoring requirements. If these clinicians choose not to participate, they will not be required to report to MIPS and will not receive a MIPS payment adjustment.

If the Advanced APM also happens to be a MIPS APM, and the Partial QP chooses to participate in MIPS, then the Partial QP will be scored under the APM Scoring Standard.

To become a Partial QP, you must meet or exceed 20 percent payments for professional services or 10 percent patients delivered professional services through an Advanced APM entity at one of the determination periods (snapshots).

Flexibility for Small Practices to Participate in Advanced APMs

The Advanced APM risk requirement has been updated so that it can be defined in terms of either total Medicare expenditures or participating organizations' Medicare revenue.

Snapshots

CMS will make QP determinations using each Advanced APM entity's Participation List at 3 "snapshot" dates: March 31, June 30, and August 31. For each of the 3 QP snapshot dates, CMS will use the APM entity's Medicare administrative claims data from January 1 through the snapshot date to calculate Threshold Scores.

For additional information about thresholds, QP determinations, and snapshot dates, please review the QP Methodology Fact Sheet.

UPDATEDWe established a fourth snapshot date of December 31st for full TIN APMs (Medicare Shared Savings Program) for determining which eligible clinicians are participating in a MIPS APM for purposes of the APM scoring standard.

  • This allows participants who joined full TIN APMs between September 1st and December 31st of the performance year to benefit from the APM scoring standard.

The fourth snapshot is not part of the Qualifying APM Participant snapshot dates.

Advanced APM Participation

Prepare to Participate

If you are an eligible clinician and are interested in preparing to participate in an Advanced APM, you should consider these technical assistance options:

  • Learn about Direct Technical Assistance for help participating in the Quality Payment Program. One resource to help prepare for participating in the Quality Payment Program is the Transforming Clinical Practice Initiative (TCPI).
  • The CMS-supported Transforming Clinical Practice Initiative (TCPI) helps you and more than 140,000 other clinicians share, adapt, and develop comprehensive quality improvement strategies. If you participate in the program, you’ll be able to successfully participate in MIPS or learn how to successfully move toward participating in APMs and Advanced APMs.

You can receive further support with our technical assistance resources.

Join

  1. Learn about specific Advanced APMs and how to apply.
  2. Apply to an Advanced APM that fits your practice and is currently accepting applications.

Current Participants

If you are an eligible clinician currently participating in an Advanced APM (see Advanced APM List), please contact your APM entity for participation specifics.

2018 Advanced APMs

In Performance Year 2018, the following models are Advanced APMs:

Advanced APMOverviewUPDATEDBundled Payments for Care Improvement (BPCI) AdvancedThe Bundled Payments for Care Improvement (BPCI) initiative is comprised of 4 broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care.Comprehensive ESRD Care (CEC) – Two-Sided RiskThe Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD).Comprehensive Primary Care Plus (CPC+)Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.UPDATEDMedicare Accountable Care Organization (ACO) Track 1+ ModelThe Medicare ACO Track 1+ is a time-limited model for Track 1 Medicare Shared Savings Program (Shared Savings Program) ACOs. The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to provide coordinated, high-quality care to their Medicare patients. Track 1+ Model ACOs assume limited downside risk (less than Track 2 or Track 3).Next Generation ACO ModelBuilding upon experience from the Pioneer ACO Model and the Shared Savings Program, the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.Medicare Shared Savings Program – Tracks 2 and 3The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to provide coordinated, high-quality care to their Medicare patients. Track 2 and 3 ACOs may share in savings or repay Medicare losses depending on performance. Track 2 ACOs may share in a greater portion of savings than Track 1 ACOs. Track 3 ACOs take on the greatest amount of risk but may share in the greatest portion of savings if successful.Oncology Care Model (OCM) – Two-Sided RiskUnder the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1-CEHRT)The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR). 

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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

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.

Learn more about MIPS APMs.

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.

Learn more about Advanced APMs.

Advanced MIPS APMs

These models have both types of participants under one model name. Each participant’s eligibility is based on the level of participation within the model.

All-Payer/Other-Payer Option

Starting in Performance Year 2019, eligible clinicians will be able to become Qualifying Alternative Payment Model Participant (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.

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All-Payer Advanced Alternative Payment Models (APMs) Option

Starting in the 2019 QP Performance Period, eligible clinicians will be able to become Qualifying Alternative Payment Model Participant (QPs) through the All-Payer Option. This Option is attainable through participation in a combination of Advanced APMs with Medicare and Other-Payer Advanced APMs.

Qualifying APM Participant (QP)

The Advanced APM path provides 2 ways for eligible clinicians to become QPs:

  • The Medicare Option, which takes into account the clinician’s participation solely in Medicare Advanced APMs, and;
  • The All-Payer Option, which takes into account the clinician’s participation in Advanced APMs both with Medicare and other payers.

An eligible clinician’s QP status is determined by 2 thresholds for Advanced APM participation: one for patient count and one for payment amounts. Beginning in 2019, eligible clinicians who do not meet either threshold under the Medicare Option, but meet a minimum threshold under the Medicare Option, may request a QP determination under the All-Payer Option. Eligible clinicians who are determined to be QPs through either option will receive a 5 percent APM incentive payment in the payment year and will not be subject to the MIPS reporting requirements or payment adjustments.

QP Performance Period

The performance period is the same for both the Medicare Option and the All-Payer Option. QP determinations are made using data submitted by eligible clinicians or APM entities for one of the snapshot dates: March 31, June 30, and August 31.

Other-Payer Advanced Alternative Payment Models (APMs)

Other-Payer Advanced APMs are non-Medicare Fee For Service (FFS) payment arrangements with other payers including:

  • Medicaid
  • Medicare Health Plans (including Medicare Advantage, Medicare-Medicaid Plans, 1876 Cost Plans, and Programs of All Inclusive Care for the Elderly (PACE) plans)
  • Payers with payment arrangements in CMS Multi-Payer 4 Models; and
  • Other commercial and private payer arrangements that meet the criteria to be an Other-Payer Advanced APM.

To be an Other-Payer Advanced APM, payment arrangements must meet the following 3 criteria:

  1. The arrangement must require use of certified EHR technology (CEHRT). The other payer payment arrangement requires at least 50 percent of eligible clinicians in each participating APM entity group to use CEHRT to document and communicate clinical care information.
  2. The arrangement must base payments for covered professional services on quality measures that are comparable to the MIPS Quality performance category. There must be evidence-based, reliable, and valid quality measures, with at least one outcome measure if available on the MIPS measure list.
  3. The arrangement must require participants to bear a certain amount of financial risk. A payment arrangement meets the financial risk if actual expenditures exceed expected aggregate expenditures, or be a Medicaid Medical Home Model that meets criteria comparable to Medical Home Models.

Medicaid Other-Payer Advanced APM

Under the All-Payer Option, these entities may submit information to CMS about their payment arrangements with eligible clinicians:

  • State Medicaid Agencies
  • Medicare Advantage
  • other Medicare Health Plans
  • commercial and private payers participating in CMS-sponsored Multi-Payer payment arrangements

CMS will determine whether each submitted payment arrangement constitutes an Other-Payer Advanced APM for a given Performance Year. If a payer chooses or is not eligible to submit its arrangements to CMS, participating eligible clinicians or APM entities may do so. You can review the list of determined Medicaid Other-Payer Advanced APMs (hyperlink) before choosing to complete the Eligible Clinician Initiated Submission Form.

CMS Determination of Other-Payer Advanced APMs

Prior to each QP Performance Period, CMS will make Other-Payer Advanced APM determinations based on information submitted by payers. CMS will review the payment arrangement information submitted by each payer to determine whether it meets the Other-Payer Advanced APM criteria. Once reviewed and approved, CMS will post a list of Other-Payer Advanced APMs online before the QP Performance Period. If the payer was determined to be an Other-Payer Advanced APM, the clinicians practicing under that payer would not be need to partake in the submission process. Clinicians who do not see a determination for their payer may submit, for approval, to CMS that they are practicing as part of an Other-Payer Advanced APM.

The Medicaid Eligible Clinician Initiated Submission Form

The Medicaid Eligible Clinician Initiated Submission Form is now available. The form may be used to request that CMS determine whether such payment arrangements are Other-Payer Advanced APMs under the Quality Payment Program. The process is called the APM entity or Eligible Clinician Initiated Other-Payer Advanced APM Determination Process (Eligible Clinician Initiation Process).

CMS will review the payment arrangement information in this form to determine whether the payment arrangement meets the Other-Payer Advanced APM criteria. Additional details and explanation about the submission process are available by selecting the Medicaid Eligible Clinician Initiated Submission Form.