Merit Based Incentive Program (MIPS)


This year, CMS is launching their MIPS initiative to replace other programs, such as, PQRS and MU. MIPS (Merit Based Payment Incentive Payment system) and APM's (Advanced Alternative Payment models) are two tracks clinicians can take as part of the Medicare MACRA initiative. The track chosen by most clinicians is MIPS and this is the one we will address. It is coming up fast! By now, each of you should have received a letter from CMS discussing this new program and defining your status for reporting. You can have each eligible physician (EP), i.e., your radiologists, report as an individual, or you may want to have them report as a group, you will find the guidelines at https://qpp.acr.org/.

Do you need to report via MIPS?

The first step is to determine if your radiologists need to report, per MIPS. You can check if you are exempt from MIPS participation by going to this web site and entering your NPI. https://qpp.cms.gov/participation-lookup. If a physician bills Medicare $30,000 in Part B billing and/or sees at least 100 Medicare patients, you must enroll and report through MIPS. Radiologists are also exempt if they are enrolled in the Advance Payment Model (APPM).

MIPS is a phased in roll out and could result in up to +9% additional Medicare payments. Here is the payment schedule over time. You can also earn an additional 4% bonus payments for your 2019 payment adjustment if you report in 2017. MIPS Although there are four categories of reporting, three for 2017, radiologists are considered as non-patient facing and, as such, have to report against two categories.
  1. Quality– 85% of their target
  2. Improvement Activities – 15% of their target.
Points are assigned to each of the items selected. For example, improvement activities could have a rating of 10% or 20%. In order to meet the target, the total percentage of items selected should be equal to the target percentage. See https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf

2017 is a transition year and there are several levels of participation.
  1. The quick method is the test level and it is to report on one quality measure OR one improvement activity. Doing this would mean there would be no penalty in your 2019 payment adjustment, but no upside either.
  2. The second is to report on 90 days on multiple quality measures and/or improvement activities and you may earn neutral or positive payment adjustment. If that option is chosen then the quality measures and improvement activities you select would be tracked and submitted for a 90-day period, October-December 2017. This could provide some upside on the reimbursement.
  3. The third option would be to report for the full 2017 year, which could give even greater upside on payments.

  4. Reporting needs to be done thru a Qualified Clinical Data Registry (QCDR). The one we recommend is the NRDR's (National Radiology Data registry) QCDR. There is a cost for reporting performance measures and activities to CMS for MIPS; however, the cost is minimal for ACR members.

What is medQ doing for this?

medQ, Inc. has created a special MIPS reporting module to produce certain data to submit to these registries. The Omnicare program can also produce the data that can be reported thru these registries, for breast and lung categories. More info about the ACR registry can be found at https://www.acr.org/Quality-Safety/National-Radiology-Data-Registry/Qualified-Clinical-Data-Registry

Data must be submitted to this registry by January 31st 2018. This gives the ACR enough time to submit that data to CMS on your behalf to avoid a negative payment adjustment.

We have identified a number of "Quality Performance measures" and "Improvement Activities" we feel are appropriate for our customers. All measures require the "Q/ris MIPS reporting module" however add on modules are required for specific measures s indicated below:

Quality Performance measures:

For an overview of Quality Performance measures see https://qpp.cms.gov/mips/quality-measures. For 2017 quality measures reporting both MIPS and non-MIPS measures are allowed. There are 52 2017 MIPS and Non-MIPS measures to choose from and the ACR has provided a list here https://www.acr.org/Quality-Safety/Resources/MACRA-Resources. Here are the ones we recommend:



With the addition of the "Q/ris Dose Capture Module" you can report on these additional quality measures:



There are other measures which require more work at the site. These are:



With the addition of the "Q/ris Mammography module" you can also report on the following quality measures:



Improvement activities:

"Improvement Activities" for the most part are reported thru the same QCDR used for reporting "Quality Performance measures" however the submission process is like attestation. It can also be reported thru the CMS website much like those of you who did Meaningful Use attestation. You say yes or no to the measures you report however in case of an audit there must backup the attestation. For an overview of "Improvement Activities" see https://qpp.cms.gov/mips/improvement-activities. The full list of ACR suggested Improvement activities can be found in the link in the Tools section at https://www.acr.org/Quality-Safety/Resources/MACRA-Resources. We can work with each site to help pick and choose the appropriate "Improvement activities" which are right for the site.

Additional measures will be available with the Q/ris CDS module (appropriate use criteria) coming in 2018. If you decide to move forward with this please contact medQ. Keep in mind the following dates:

If you are interested in adding this to your program, give us a call. 214-221-6330 ext 225 or email me at John@medQ.com.

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