• MIPS Manual 2017—2017 ACI Transition Measures

    Written By: Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content was excerpted from EyeNet’s MIPS Manual 2017.


    Your CEHRT determines which measures set you can report. If your EHR system is a 2014-certified CEHRT, you must select the 2017 ACI transition measures set. If your EHR system is a 2015-certified CEHRT, you can choose to report either the 2017 ACI transition measures set or the ACI measures set. (MIPS tip. The Academy recommends that you report the 2017 ACI transition measures, which will be easier to achieve than reporting the ACI measures.)

    There are 11 2017 ACI transition measures:

    • 4 measures are mandatory—all 4 must be reported for the base score and 2 of them also contribute to the performance score
    • 7 measures are optional—5 of these contribute to the performance score; 2 can be used to earn the registry bonus

    Base Score Measures

    Measure Required or Optional? Reporting Requirement
    Security Risk Analysis Required Yes/No Statement*
    e-Prescribing Required Numerator/Denominator
    Provide Patient Access Required Numerator/Denominator
    Health Information Exchange Required Numerator/Denominator
    All or nothing. If you successfully report all 4 measures, your base score contributes 50% to your overall ACI score. If you fall short, even by just 1 measure, your base score is 0% and your ACI score is 0%.

    Performance Score Measures

    Measure Required or Optional? Contribution to ACI Score Reporting Requirements
    Provide Patient Access Required Up to 20% Numerator/
    Denominator
    Health Information Exchange Required Up to 20% Numerator/
    Denominator
    Patient-Specific Education Optional Up to 10% Numerator/
    Denominator
    View, Download, or Transmit (VDT) Optional Up to 10% Numerator/
    Denominator
    Secure Messaging Optional Up to 10% Numerator/
    Denominator
    Medication Reconciliation Optional Up to 10% Numerator/
    Denominator
    Immunization Registry Reporting Optional 0% or 10% Yes/No Statement*

    Registry Bonus Measures

    Measure Required or Optional? Contribution to ACI Score Reporting Requirements
    Syndromic Surveillance Reporting Optional 0% or 5% Yes/No Statement*
    Specialized Registry Reporting Optional 0% or 5% Yes/No Statement*

    Only need to report 1 measure for the bonus. Reporting 1 of these 2 measures earns you the full 5% bonus.

    Use the IRIS Registry. Integrating your EHR system with the IRIS Registry will satisfy the Specialized Registry Reporting measure.

    How the measures contribute to your ACI score. First, you must successfully report all the base measures. If you do, your ACI score = base score (50%) + performance score (0%-90%) + registry measure bonus (0% or 5%) + CEHRT for improvement activities bonus (0% or 10%).

    Note: Your ACI score is capped at 100%, and it contributes up to 25 points to your MIPS final score (e.g., an ACI score of 80% contributes 20 points to your MIPS final score).

    *To successfully report a “Yes/No” measure, attest (“Yes”) that you performed the activities that the measure requires. If you attest “No,” you fail the measure. Make sure you document the activities that you performed.

    To successfully report numerator/denominator measures for the base score, you need a numerator of at least 1.  For the e-Prescribing measure, for example, the denominator is the number of prescriptions written for drugs during the performance period and the numerator is the number of those prescriptions that were 1) generated, 2) queried for a drug formulary, and 3) transmitted using a CEHRT. For the base score, you need a numerator of at least 1 and you get no extra credit for a numerator that is more than 1.

    When reporting numerator/denominator measures for the performance score, your score will depend on your performance rate. For example, suppose you report the Patient-Specific Education measure. The denominator for that measure is the number of unique patients seen during the performance period. The numerator is the number of those patients (or their authorized representatives) who were given electronic access to patient-specific education based on clinically relevant information identified from your CEHRT. If the numerator was 200 and the denominator was 600, then your performance rate is 33.33% (200/600). This measure can contribute up to 10% to your ACI score. Scoring is decile based, and a score of 31-40% would contribute 4% to your ACI score.

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    Next: Download an at-a-glance PDF of the 2017 ACI transition measures (plus measure descriptions) or read about the ACI measures set

    Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    COPYRIGHT© 2017, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry are trademarks of the American Academy of Ophthalmology®.