MACRA 101: Advancing Care Information

The Merit-Based Incentive Payment System (MIPS), initiated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), consolidates parts of the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier and the Medicare Electronic Health Record (EHR) Incentive Program into a single program for eligible professionals. These proposed changes do not apply to hospitals or critical access hospitals. MIPS consists of four components:

  • Quality reporting
  • Resource use
  • Clinical practice improvement
  • Meaningful use of certified EHR technology

The exact MACRA requirements will be finalized by early November. In the meantime, the following information provides insight into plans that the Centers for Medicare and Medicaid Services (CMS) has for the program.

Advancing Care Information

Under MIPS, the requirement to meaningfully use certified EHR technology is referred to as Advancing Care Information (ACI), which replaces the Medicare EHR Incentive Program for clinicians.

MIPS Eligible Clinicians

Only physicians are currently eligible to participate in the Medicare EHR Incentive Program. Under the proposed rule, the ACI component of MIPS would expand this to include nurse practitioners and physician assistants in years 1 and 2. CMS has proposed expanding the category of eligible clinicians to include physical and occupational therapists, audiologists, nurse midwives, clinical social workers and nutrition professionals after year 3. All MIPS eligible clinicians would be able to participate as individuals or as members of a group.


CMS has proposed that the ACI category account for 25 percent of the MIPS total score in the first year.  The ACI score would consist of a base score and a performance score. There is also the possibility of a one-point bonus. 

Base Score

To receive the base score of 50 points for the ACI category, clinicians would need to report at least once for each applicable measure. If even one is missed, clinicians would earn a 0 for the entire ACI category of the MIPS Composite Score.

Performance Score

CMS’ proposal would allow eligible clinicians to earn up to 80 points towards the performance score. This score would be based on an eligible clinician’s performance on the eight measures that compose the following three objectives:

  • Patient Electronic Access
  • Coordination of Care Through Patient Engagement
  • Health Information Exchange

Because the maximum point total for the ACI component of the MIPS Composite Score is capped at 100 points, clinicians would have some flexibility to focus only on some of the measures attributable to the performance score.

Bonus Point

An eligible clinician would only be required to report on the Immunization Registry Reporting measure for the Public Health and Clinical Data Registry Reporting objective. Completing any additional measures under the objective, such as reporting to a specialized registry (i.e., the PINNACLE Registry), would earn one additional bonus point after calculation of the performance score.

Objectives and Measures

Under the proposed rule, eligible clinicians would begin reporting on the ACI objectives and measures in 2017 with payments adjusted in 2019. In 2017 clinicians would have three options:

  • Use 2014 edition certified technology and report on the eight modified Stage 2 measures
  • Use a combination of 2014 and 2015 edition certified technology and report on the modified Stage 2 measures or Stage 3 measures (if their technology permits)
  • Use 2015 edition certified technology and report on the Stage 3 measures 

Beginning in 2018, clinicians would need to use 2015 edition certified technology and report on the six Stage 3 measures.

While the ACI performance category of MIPS reporting requirements is somewhat different than those established in the 2015 Medicare and Medicaid EHR Incentive Programs, they do borrow heavily from the previous programs.

A table comparing the Final Measures and Objectives for 2015 - 2017 to the proposed Modified Stage 2 and Stage 3 Measures and Objectives can be found here

Additional Health IT Requirements

In addition to the ACI component of MIPS, CMS has proposed two additional requirements for clinicians: cooperation with the government’s health IT surveillance activities and certification that they are not engaged in information blocking.

Under the proposed rule, CMS would require that clinicians agreed to cooperate with any activities conducted by the Office of the National Coordinator (ONC) for Health IT pertaining to health IT surveillance and oversight activities regarding the performance of the certified EHR technology capabilities in use by the clinician. These surveillance and oversight activities would include responding to requests for information from ONC or their authorized agents’ inquiries in a timely manner. 

The proposed rule also would require that clinicians attest that they have not knowingly and willfully taken action (such as to disable certain functionalities) to limit or restrict the compatibility or interoperability of certified EHR technology. 

Resources for EHR purchasers and Users

CMS has made a number of resources available to help clinicians and administrators prepare to participate in the Medicare and/or Medicaid EHR Incentive Programs. These resources include an EHR Contract Guide for those preparing to purchase or upgrade an EHR, and the Health IT Playbook, a guide for users seeking maximize the use of health IT to advance care information and delivery. Registration and attestation guidance and contact information for CMS EHR Incentive Program technical assistance can be found here

2018 Payment Adjustment

Under the proposed rule, clinicians who have not successfully demonstrated meaningful use in a prior year and would be reporting for the first time in 2017 need to attest by Oct. 1, 2017, to avoid the 2018 payment adjustment.

Hardship Exemption

CMS has proposed a new hardship exemption for eligible clinicians who are new participants in the EHR Incentive Program beginning in 2017 and want to avoid penalties. This exemption would apply to clinicians that have not demonstrated meaningful use in a prior year, intend to attest to meaningful use by Oct. 1, 2017, and will be transitioning to the MIPS program.

Quick Tips to Prepare for Advancing Care Information

  • Determine the status of your current EHR Incentive Program participation.
  • Decide if you will be implementing new EHR technology, or readying existing technology to meet the MIPS objectives and measures for ACI. 
    • Review the EHR Contracting Guide and Health IT Playbook to explore the purchase or upgrade of Certified Health IT to meet the MIPS objectives and measures.
    • Reach out to a vendor of Certified Health IT who can assist you in preparing your EHR system and staff for MIPS reporting.
  • Evaluate if your organization is meeting the current objectives and measures using this comparison table.
  • Enroll in the PINNACLE Registry and qualify for a Public Health Registry Bonus Point on your total ACI Performance Category Score

Review "MACRA: A New Era for Medicare Payment" for an overview of how the new payment system will impact you and your practice. Get up-to-speed on the MIPS Quality Payment Program. Stay tuned for articles on the other core components of MIPS: resource use and clinical practice improvement. A list of MACRA frequently asked questions is also available.

Keywords: Centers for Medicare and Medicaid Services (U.S.), Certification, Electronic Health Records, Meaningful Use, Medicaid, Medicare, Nurse Midwives, Nurse Practitioners, Patient Participation, Physician Assistants, Physicians, Pregnancy, Public Health, Registries, Social Work

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