MACRA MIPS Basics and What You Need to Do Now

By now, your organization, hopefully, is on its way on deciding what level of participation your organization should take on reporting MACRA for 2017. The Medicare Quality Payment Program (QPP), which began in January 1, 2017 applies to physicians, NPs, PA, CRNs, Nurse Anesthetists (not hospitals or facilities) and must participate in either the Merit-Based Incentive Payment System (MIPS) or in an advanced Alternative Payment Model (APM). Because greater than 50% of Clinicians are MIPS-eligible, we will focus on MIPS.

You are not MIPS-eligible if any of the following apply:

  • You are newly enrolled in Medicare
  • You see 100 or fewer Medicare Part B patients per year
  • You have less than or equal to $30,000 allowed Medicare Part B charges annually
  • You are on the participant list on at least one of 3 snapshot dates (3/31, 6/30, or 8/31) for a model that CMS has deemed an Advanced Alternative Payment Model (AAPM) for purposes of QPP participation. See the Centers for Medicare & Medicaid Services (CMS) list of AAPMs


Unless you have an exclusion from MIPS due to any of the reasons mentioned above, you must participate in the program in 2017. Understanding the different requirements in all 3 categories is essential in deciding your level of involvement for 2017. Those categories are:

  • Quality: Report on quality data on clinician-selected measures. This category is a replacement for CMS’ Physician Quality Reporting System (PQRS) and includes nearly 300 possible Quality measures (for example, providing receipt of specialist report or documentation of current medications in the medical record). Additional measures may be available through your specialty society’s Quality Clinical Data Registry (QCDR).
  • Advancing Care Information (ACI): Report on performance on certain Electronic Health Record (EHR) measures. This is the replacement for CMS’ EHR Incentive Program (Meaningful Use) and requires use of Certified Electronic Health Technology (2014-CEHRT).
  • Improvement Activities (IA): Attests to performance on certain CMS-designated improvement activities (for example, annual registration in a Prescription Drug Monitoring Program or improvements to care transition in the 30 days following patient discharge).


You have a choice of three participation tracks in 2017 to avoid a 4% penalty on your 2019 Medicare reimbursement. You should choose your participation track based on how you think you will perform on Quality, ACI, and/or IA performance categories. The tracks are:


  1. Minimum Participation: Avoid any penalty and report performance on either:
  • 1 Quality measure; or
  • 1 IA (Improvement Activity), either high or medium weight (depending on practice size); or
  • 4 or 5 base score ACI (Advancing Care Information) measures (depending on whether you have a 2014 or 2015 certified EHR, respectively)
  1. Partial Participation: Report on as many activities as feasible to be eligible for upside bonus. Keep in mind that because the program is based on a balance budget and virtually no penalties will be distributed, there will be very limited upside bonus available.
  • More than 1 (6) Quality measure; or
  • More than one IA (2-4); or
  • Base score ACI measures plus at least one additional ACI measure (core EHR measures plus up to 50 points in additional reporting)


  1. Full Participation: Excellent performers are eligible to share $500 M across the country but will be competing among organizations that have been focused on quality measurement for years:
  • 6 Quality measures, including one outcome measure; and
  • A combination of high- and medium-weight IAs (exact number will vary based on practice size and rural or non-rural location); and
  • Base score ACI measures plus any additional performance or bonus measures


You do not have to elect a participation pace as CMS will determine your pace based on the data that you submit. Still unsure of the pace or your involvement in 2017? To better understand how you may perform in the MIPS program and tailor your participation in 2017, review your past performance in other Medicare quality programs, such as PQRS, the EHR Incentive Program (Meaningful Use), and the Value Based Modifier (VBM). You can use your September 2016 Quality Resource Use Report (QRUR) or your 2016 PQRS Feedback Report to assess future performance. These reports have drill down tables that feature performance by group and individual, and can help you understand how you’ve done in the past and how you might do in the future.


You might consider minimum participation if you have no PQRS or just implemented your CEHRT. Partial participation might be the path if you have been on a CEHRT and have reported PQRS in the past, but are facing some physician resistance. You can also use 2017 as your trial run to prepare you for 2018.


Regardless of the path you choose to report in 2017, remember that this is a 2-year process. You will be working on your 2018 process before you know your 2017 results. Lastly, remember that you can successfully participate in the Minimum Participation track and avoid the 4% penalty by reporting one Quality measure. However, if you plan to participate in the Full or Partial Participation tracks, CMS requires a minimum 90 day participation period, which means that you must begin participating in those activities no later than October 2, 2017.

Paulette DiCesare -RN

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