• MIPS 2017—Know the Basics: General Overview

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

    This Practice Perfect content is part of EyeNet’s Guide to MIPS 2017.

    Medicare’s new payment system—the Quality Payment Pro­gram (QPP)—launches on Jan. 1, 2017, though you don’t necessarily have to start participating until later in the year (see “Performance Period,” below).

    The Quality Payment Program provides 2 pathways: MIPS and APMs. You can participate either in the Merit-Based Incentive Payment System (MIPS) or in an advanced alternative payment model (APM). MIPS includes a hybrid option—the MIPS APM—for clinicians who are in certain types of accountable care organizations (see “MIPS 2017—Know the Basics: APMs in Brief”).

    This series will focus on MIPS. Advanced APM options will initially be limited for ophthalmology, so most Academy members will be MIPS partic­ipants. If you have participated in CMS’ previous quality reporting programs—such as the Physician Quality Reporting System (PQRS)—then many aspects of MIPS reporting will seem familiar to you.

    Some initial wiggle room. For MIPS’ inaugural year, CMS has increased reporting flexibility, eased the reporting requirements, and made it quite easy to avoid the payment penalty.

    More help online. In addition to the current series of EyeNet articles, you can go online for explanatory materials from CMS and the Academy.

    Scoring, Bonuses, and Penalties

    You will receive a final score (0-100 points) for your 2017 performance that will impact your 2019 payments. If your 2017 final score is:

    • 0 points, your 2019 Medicare payments will suffer a payment penalty of 4%
    • 3 points, you’ll get no penalty and no bonus
    • More than 3 but less than 70, you will get a small bonus
    • 70-100 points, you will get a modest bonus 

    Where the bonus money comes from. The penalties imposed on some clinicians are used to finance the bonuses paid to their colleagues. Because it is easy to avoid the penalty during the 2017 performance year, that bonus pool will be small. However, CMS is also putting $500 million into a second bo­nus pool that will be used to augment the bonuses of those MIPS participants who have a final score of 70 or more.

    The final score is based on 3 perfor­mance categories. Two of the 3 evolved out of earlier CMS programs, though with some sweeping changes:

    • Quality replaces PQRS. For larger practices, it includes a population-based measure from the Value-Based Modifier (VM) program. Quality con­tributes 60% to the final score for the 2017 performance year, falling to 50% for 2018, and 30% for 2019.
    • Advancing care information (ACI) replaces the electronic health record (EHR) meaningful use (MU) program. It counts for 25% of the final score.
    • Improvement activities is entirely new. It counts for 15% of the final score. (Note: This category was called clinical practice improvement activities in the initial draft of the regulations.) 

    Next year, cost is added to the equation. Starting in 2018, a fourth performance category will contribute to the final score:

    • Cost replaces the VM program. It contributes 0% to the final score in 2017, 10% in 2018, and 30% in 2019. (Note: This category was called resource use in the initial draft of the regulations.)

    Avoid the Payment Penalty

    During the inaugural year of MIPS, avoiding the penalty is easy. For the 2017 performance year, attain a final score of at least 3 points to avoid a penalty. To do that, you can:

    • Submit data on 1 quality measure 1 time on 1 patient to score 3 points or
    • Report on 1 improvement activity to score 10 points

    MIPS tips. Keep in mind the follow­ing:

    • Consider reporting more than 1 qual­ity measure for a period of more than 1 day and more than 1 improvement activity—just in case there is a problem with the first one that you report.
    • If you are reporting a quality measure by claims, submit it multiple times—just to make sure it goes through.
    • Get up to speed during 2017—rather than reporting the bare minimum, try to maximize your reporting so you’ll be ready for future years when the require­ments aren’t so flexible.

    Performance Period

    For 2017, CMS has set the performance period at 90 consecutive days. You don’t have to tackle all the performance categories at the same time—each category could have a different 90-day performance period. Note: For quality, although you must satisfy this 90-day threshold in order to score more than 3 points on a measure, you can still score 3 points with a shorter performance period (see “MIPS 2017—Know the Basics: Quality Overview”).

    Consider reporting for more than 90 days. You are likely to get a better quality score with a longer performance period—ideally a full calendar year. You will, for instance, increase the likeli­hood that you meet the case minimum threshold for quality measures (see “Submission thresholds” in “MIPS 2017—Know the Basics: Quality Overview”). And for some quality mea­sures, your performance will be judged against benchmarks that are based on 12 months of data. Furthermore, you will boost your preparedness for the 2018 performance year, when the per­formance period for quality becomes 1 calendar year.

    MIPS tip. If you are using IRIS Reg­istry/EHR integration to submit quality data, an automated process is used to extract that data—so there is no extra reporting burden associated with sub­mitting data for the full calendar year.

    Who Does (and Doesn’t) Take Part in MIPS

    CMS introduces a new term—the MIPS eligible clinician. MIPS eligible clinicians are defined as physicians (which, for this purpose, includes op­tometrists), physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthe­tists, as well as groups that include such clinicians.

    Not all MIPS eligible clinicians must participate in MIPS. You are exempt from MIPS if 1 of the following 3 exclusions applies.

    Exclusion 1—MIPS eligible clinicians who are new to Medicare. If you enroll in Medicare for the first time in 2017, and have not previously submitted claims under Medicare, you will be exempt from the MIPS rules for the 2017 performance year.

    Exclusion 2—MIPS eligible clini­cians who are below the low-volume threshold. You will be exempt from the MIPS rule if, over a 12-month period (see below), you:

    • Bill Medicare Part B for no more than $30,000 or
    • Care for no more than 100 Medicare Part B beneficiaries. 

    You have 2 chances to qualify for the low-volume exemption. To see if you are exempt for the 2017 perfor­mance year, CMS will review your data for 2 time periods:

    • Sept. 1, 2015, to Aug. 31, 2016
    • Sept. 1, 2016, to Aug. 31, 2017 

    If you are below the low-volume threshold during either of these time periods, you will be exempt—even if you surpass the threshold in the other time period.

    Exclusion 3—MIPS eligible clini­cians in advanced APMs. If you are participating in an advanced APM (see “MIPS 2017—Know the Basics: APMs in Brief”), you may be exempt from the MIPS rule if you satisfy the APM track’s reporting thresholds.

    Use of TINs and NPIs as Identifiers

    Individuals. If you are participating in MIPS as an individual, CMS will use both your Tax Identification Number (TIN) and National Provider Identifier (NPI) to distinguish you as a unique MIPS participant. You must use the same TIN/NPI combination for all performance categories. If you report more than 1 TIN/NPI combination—because, for instance, you practice in more than 1 location or you move to a new practice—you will be assessed separately for each TIN. Physicians in such situations should meet the reporting requirements at both NPI/TIN combinations where they practice during the performance year.

    MIPS groups. If you and your colleagues choose to participate jointly as a group, the group’s TIN alone will be your identifier for all 4 categories. Typi­cally, no registration is required to participate in MIPS as a group; the excep­tion is if you are using the CMS Web Interface or the CAHPS for MIPS survey.

    APM entity group. If you and your colleagues participate jointly as an APM entity group, each MIPS eligible clinician within that group would be identified by a unique APM participant identifier. For example, all clinicians participating in a track 1 ACO will receive the same score.

    Bonuses and penalties. Payment adjustments will be applied at the TIN/NPI level, regardless of whether you participate in MIPS as an individual, as part of a MIPS group, or as part of an APM entity group.

    Your payment adjustment will follow you to your next practice. Your final score for the 2017 performance year will impact your payment adjustment during the 2019 payment year, and—unlike PQRS—this is the case even if you move to a new practice after the 2017 performance year finishes. In other words, when CMS determines your 2019 payment adjustment, it will look at the 2017 final score that was associated with the TIN you were using in 2017, not the 2017 final score that is associated with your new practice’s TIN.

    Next Steps

    Decide how you will report. You don’t have to use the same reporting mecha­nism across all performance categories. For instance, you can report quality and improvement activities using the IRIS Registry and report ACI using your EHR vendor. However, within each performance category, you typi­cally must use just 1 reporting mecha­nism—the exception is the CAHPS for MIPS survey, which can be used as a second data submission mechanism for quality but won’t be applicable for most ophthalmologists.

    The IRIS Registry is expected to be the MIPS tool of choice. The IRIS Registry provides 2 platforms for MIPS quality reporting—one involves EHR (automated ex­traction of data from your records) and the other doesn’t (manual entry of data into a Web portal). The IRIS Registry is also planning to offer reporting options for ACI and improvement activities. (Note: Registries that are used for MIPS reporting are recertified annually; CMS isn’t scheduled to recertify 2017 registries and their 2017 non-MIPS measures until April 2017.)

    Consider group reporting. Your practice can report as a group if it in­cludes at least 2 MIPS participants. You don’t need to register as a group unless you’re planning to report via the CMS web interface or the CAHPS for MIPS survey. Note: You must participate in the same way (either as an individual or a group) for all performance categories.

    MIPS tip: If a practice takes part in MIPS as a group, and 1 MIPS eligible clinician within that group reports an improvement activity, the whole group can get credit for that activity.

    Physician leadership is crucial. Although CMS has made it easy to avoid the payment penalty during MIPS’ inaugural year, the reporting requirements—and the payment pen­alties—are expected to ramp up rapidly over the next 2 or 3 years. Because so much money will ultimately be at stake, a physician ought to oversee your practice’s MIPS planning and processes, which should be implemented by ex­perienced staff who are knowledgeable about MIPS’ precursors (PQRS, EHR MU, and VM).


    This content is excerpted from Part 1: Know the Basics (Practice Perfect, January 2017 EyeNet; published online in advance of print), which is part of EyeNet’s Guide to MIPS 2017.  Part 1 includes General Overview, Quality Overview, Advancing Care Information Overview, Improvement Activities Overview, and APMs in Brief.

    Note: This content was based on the information available at time of press; CMS is still publishing its regulatory guidance for MIPS.