While the MACRA Quality Payment Program has two tracks for providers to choose from, the Centers for Medicare and Medicaid Services (CMS) anticipates that most will choose the Merit-based Incentive Payment System (MIPS) over the Advanced Alternative Payment Models. However, since MIPS replaces three different quality programs CMS formerly offered, the way the program is scored can be complicated and confusing.
First, let’s look at how the various components of MIPS are weighted for an overall score. For the 2017 reporting year affecting 2019 payments, the cost measure will be calculated for informational purposes but will not be used in scoring. That means only the quality, improvement activities, and advancing care information categories will be scored. Cost will begin to be scored beginning with the 2018 reporting year, and the quality category will be reduced in weight.
Another key component of MIPS scoring is the end of an all or nothing approach. In each category, some points are earned by simply participating and additional points are earned through greater participation or achieving certain benchmarks. The higher or lower the score, the higher or lower the positive or negative payment adjustment during the associated payment period. Remember during the 2017/2019 transition year, minimal participation — even just submitting one quality measure for one encounter — will prevent providers from receiving any negative payment adjustments. However, even in the transition year, providers (individuals or groups) who participate more fully have the potential to earn up to a 4 percent positive payment adjustment.
For the quality category, which replaced the PQRS program, providers are generally required to report six measures, including one outcomes measure or high priority measure if an outcomes measures is not available. If providers report more than six measures, CMS will use the top six for MIPS scoring.
For most providers, a total of 60 points is possible for the quality category, including up to 10 points per measure. Groups of 16 or more will also have the readmission measure calculated for them by CMS, which will bring their total possible points up to 70. Bonus points also are available for things like reporting additional outcomes or high priority measures, but the bonus points will count only if the maximum for each measure is not scored, as a provider cannot earn more than 100 percent of the total for any category.
Just for submitting any data on a measure, providers earn 3 points. Providers can earn up to an additional 7 points to the degree that the measure meets the following criteria:
- Sufficient case volume (the measure was reported on at least 20 cases)
- Data completeness (quality data was submitted on at least 50 percent of denominator eligible cases)
- Historical benchmark exists for the measure (based on PQRS or other data; measures without historical benchmarks will be calculated from 2017 data when possible. If not possible, providers will be limited to 3 points for that measure.)
- The performance rate as compared with the benchmark (where a provider falls among 8 “deciles” of performance rates determines how many points above 3 are earned)
Benchmarks are calculated for each measure by reporting option. CMS recently released the 2017 historical benchmarks, and providers can find those on the Education and Tools tab of CMS’s QPP website.
Your quality score is then calculated as a percentage by taking the total points possible (# of measure required x 10, which will be 60 for most providers and 70 for groups of 16 or more) divided by the total points you earned plus any bonus points (2 points for each outcomes measures beyond the required 1, and 1 point for each high priority measure), and capping it at 100 percent.
Providers who report the bare minimum of one measure for the 2017 transition year will end up with a score of .05 or 5 percent. Providers who report six measures but don’t achieve even the minimum performance benchmarks will earn .30 or 30 percent.
Improvement Activities Scoring
Scoring the Improvement Activities category is fairly straightforward. Generally, participants are required to complete 4 medium-weighted activities over 90 days at 10 points each for a total of 40 points. A small subset of activities are considered high-weight, and providers can earn 20 points for each activity.
For clinicians in small, rural, and underserved practices or with nonpatient facing clinicians or groups, activities are given double points, making it easier for providers to achieve the maximum 40 points.
Your Improvement Activities score is then calculated as a percentage by taking the total points possible (40) divided by the total points you earned (based on medium- or high-weighted activities), and capping it at 100 percent.
Providers who report the bare minimum for the 2017 transition year by performing one medium-weight improvement activity would get a score of .25 or 25 percent. Providers who complete the total four required activities would get a score of 1 or 100 percent.
Advancing Care Information Scoring
Perhaps the most complicated category to score, the Advancing Care Information (ACI) category has three components, which also depend on which version of technology certification you have achieved with your current EHR (Advancing Care Information Objectives OR 2017 Advancing Care Information Transition Objectives and Measures).
Each option has a set of base measures which must be completed to earn any points in the ACI category. Attesting to the base measures will earn providers 50 percent of the total ACI score. Additional performance measures also can be reported (up to 7 or 9 depending on the category), with each worth up to 10 percent of the total ACI score. Additional bonus points also are available for an additional 15 percent of the total ACI score.
Your Advancing Care Information score is then calculated as a percentage by adding the percentages from each of the three sections and capping it at 100 percent.
Providers who report the bare minimum for the 2017 transition year by completing only the base ACI measures would get a score of .5 or 50 percent. Providers who complete the base score and some performance measures could earn up to 100 percent.
Hospital-based, non patient-facing, and certain mid-level providers who were not eligible for the EHR Meaningful Use program can opt in to the Advancing Care Information performance category with some modification. However, those same clinicians can choose not to participate in the Advancing Care Information performance category and instead will have that performance category weighted to 0 percent and the Quality performance category will be reweighted to 85 percent.
A non-patient facing MIPS eligible clinician is defined as follows under MIPS: an individual MIPS eligible clinician that bills 100 or fewer patient-facing encounters including Medicare telehealth services during the non-patient facing determination period, or a group with more than 75 percent of the NPIs billing under the group’s TIN who meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period.
The non-patient facing determination period for the 2017 reporting year will initially be based on 12 months of data starting from September 1, 2015, to August 31, 2016. In order to identify any additional individual MIPS eligible clinicians and groups that may qualify as non-patient facing during the 2017 performance period, CMS will conduct another eligibility determination analysis based on 12 months of data starting from September 1, 2016, to August 31, 2017.
CMS recently published a list of non-patient facing encounter codes, which can be downloaded from the Education and Tools tab of CMS’s QPP website.
To get your total MIPS score, you multiply the percentage from each category by its overall weight, then multiply the total by 100.
For 2017, non participation in MIPS or an Advanced APM will result in an automatic 4 percent negative payment adjustment for 2019 payments. However, a score as low as 3 would be high enough to avoid the payment adjustment, and earning higher scores in each category — by participating in the 90-day or full-year options — could earn you a bonus or positive payment adjustment in 2019. CMS has indicated that providers who earn scores of 4-69 could qualify for a positive adjustment up to 4 percent, and providers who earn a score of 70 or more points could quality for a positive payment adjustment up to 4 percent and an exceptional performance bonus of .5 percent or higher.
For more information about how the 2017 MIPS will be scored, review the slides from the November 29, 2016, Merit Based Incentive Program Webinar. For steps to help you get started with MIPS for 2017, read our recent blog post “How to Get Ready for MIPS.”
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