IMP Healthcare Thought Leadership

Integrated Medical Partners Blog

November 11, 2016

MIPS and MACRA Preliminary and Final Rule Update Status

In April, the Centers for Medicare and Medicaid Services (CMS) published its proposed rules for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS). The rules outlined the transformation of the current Quality Incentive Programs (PQRS, Meaningful Use and Value-based Payment Modifier) into a new incentive program called the Quality Payment Program (QPP). In this program, CMS originally proposed having Quality account for up to 50 percent of a group’s Composite Performance Score (CPS), with Advanced Care Information (ACI) accounting for 25 percent, Clinical Practice Improvement (CPI) for 15 percent and Resource Use (Cost) for the remaining 10 percent.

The Final Rule, released this month, changed the weight score attributed to Quality from 50 percent to up to 85 percent for “non-patient facing physicians” (see more below). CMS eliminated the Resource Use (Cost) category altogether. This increased emphasis on Quality can be a big winner for groups who have successfully participated in PQRS in the past due to many similar requirements. Come 2018, however, Quality will be reduced to 50 percent and Cost Performance will account for 10 percent of a provider’s CPS. In 2019, both categories will be weighted equally at 30 percent. Physician and health system leaders will need to consider the implications of these significant changes and determine what must be done to succeed moving forward.

The Merit-based Incentive Payment System (MIPS) will become effective January 2017. Groups will need to provide certain data and information to Medicare in order to earn a payment adjustment based on evidence-based and practice-specific data sets. Based upon group performance measures reported in 2017, groups will see either a positive, neutral or negative adjustment to payments made by Medicare of up to 4 percent of the fee-for-service Medicare payments for covered professional services furnished in 2019 payments. This adjustment percentage can potentially grow to 9 percent positive or negative adjustments in 2022 and beyond.

Reporting requirements
Within the new performance categories, MACRA reduced the reporting threshold for quality measures from nine under prior programs to six and eliminated the requirement to report across three National Quality Strategy domains. Of the six measures reported, one should be an outcome measure, or if an outcome measure is not available, then another high priority measure should be reported. CMS did not finalize the requirement for reporting a cross-cutting measure by any clinician. The removal of the cross-cutting measure reporting requirement from the proposed rule represents an important change.

Next year, physicians participating in MIPS can avoid penalties if they report 90 days’ worth of one quality performance measure and one activity in the CPI category, or if they report measures of the ACI performance category. Physicians stand to earn a slight pay increase if they either report more than the required measures in the advanced care information performance category, or if they report more than one quality performance measure and more than one improvement activity. Physicians who do not report anything will get a 4 percent pay cut in their Medicare reimbursements.

Reporting measures for the other categories should be achievable through participation in registries like the Dose Index Registry and/or Providing Practice Improvement activities evidence, and Advancing Care Information evidence through a Qualified Clinical Data Registry (QCDR). The American College of Radiology (ACR) is a QCDR and is offering its services (for a fee) to all radiology groups. The American Society of Anesthesiologists’ (ASA) National Anesthesia Quality Institute is also a QCDR and will be providing similar services to the ACR.

Alternatively, organizations can self-nominate and apply to CMS through a qualification process to obtain status as a QCDR providing similar services for groups. Groups can also use the CMS Web portal for certain reporting.

Non-patient facing provision
Another key provision in the Final Rule has to do with reporting requirements for “Non-Patient Facing Physicians” – most pathologists and radiologists. In early iterations of MACRA, the non-patient facing exemption was allocated by specialty. However, it resulted in inconsistencies like a cardio imaging specialist being billed under cardiology, possibly resulting in reduced payments for the physician. When the definition was changed to a threshold rule, it initially applied only to physicians who had 25 or fewer patient-facing encounters. Instead, in the Final Rule, the exemption will apply to doctors who have 100 or fewer patient-facing encounters during a 12-month determination period.

CMS has just recently released the final list of CPT codes that will be used to determine patient-facing encounters. The 2019 MIPS payment adjustment for non-patient facing clinicians will be based on data from September 2015 to August 2016. According to Danny Hughes, PhD, of the Harvey L. Neiman Health Policy Institute, “It is important for radiologists to have a reasonable threshold to be classified as non-patient facing to ensure that radiologists are provided a fair opportunity for success under MIPS. A threshold of 100 or fewer is what our analysis recommends.”

Perhaps the most surprising aspect of the ruling is the clause dictating that if 75 percent of the group’s physicians meet the non-patient facing criteria, then the entire group does as well, providing a security blanket of sorts to interventional radiologists. “The vast majority of radiologists that do not meet the non-patient facing criteria were interventional radiologists,” said Hughes. “This will allow radiologists that primarily perform interventional procedures to continue to add value to their groups without adversely affecting the group’s opportunities to succeed in performance review under MIPS.” Groups that are classified as non-patient facing will have the ACI category eliminated and the points re-weighted to Quality, Cost and CPI categories.

We recommend carefully reviewing the tables on the third and fifth pages of the ACR’s summary.

For more information regarding the MIPS and MACRA legislation, please email us at