Under the Merit-Based Incentive Payment System (MIPS), part of the Quality Payment Program (QPP) created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), clinicians will be assessed on the quality of care provided. The Physician Quality Reporting System (PQRS) is being phased out, but the structure of the MIPS Quality component remains similar to PQRS in many ways, meaning that clinicians who are currently successfully reporting to the program should easily transition to reporting under the MIPS Quality component.
The quality reporting category applies to all MIPS-eligible clinicians (physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists) and group practices billing Medicare Part B services.
Reporting data can be done at the individual-level based on each clinician’s Taxpayer Identification Number (TIN)/National Provider Identification Number (NPI) combination, or at the group-level using a practice TIN.
Objectives and Measures
Under MIPS, clinicians will be assessed based on performance against quality measures developed by the ACC, the American Heart Association and other stakeholders. Most of these measures will be familiar to clinicians as measures reported under PQRS.
MIPS-eligible clinicians and groups attempting full participation will be required to report either:
- For most clinicians and groups: six measures, including at least one outcome measure or a high-priority measure (outcome, appropriate use, patient experience, patient safety or care coordination); or
- One specialty measure set; or
- Fifteen Centers for Medicare and Medicaid Services (CMS) Web Interface measures, available to group practices and required under some Medicare Alternative Payment Models (APMs)
Note: Requirement for reporting Quality measures in the 2017 transition year as part of CMS’ Pick Your Pace Program:
- One measure; or
- Six measures for 90 days; or
- Six measures
Participants reporting at the group-level that have 16 or more clinicians and meet sample size requirements (200 cases) will also be scored on a 30-day all cause hospital readmission measure which will be based on Medicare claims data and does not require additional reporting.
The process of reporting quality measures will remain similar to what clinicians and practices are currently familiar with under PQRS. Measure data can still be submitted via claims, electronic health records (EHRs), qualified registries, or a Qualified Clinical Data Registry (QCDR) such as the ACC's PINNACLE Registry and Diabetes Collaborative Registry. Reporting via a QCDR will continue to offer benefits, such as the ability to report measures outside of those approved as "MIPS measures".
Clinicians or groups will receive 3-10 points for each measure based on performance against a historical benchmark. Zero points will be awarded for measures in which there is no data. All reported measures for which there is data will be averaged to create a score for the category.
Bonus points will be rewarded for reporting "high priority measures" related to outcome, patient experience, appropriate use, patient safety and EHR reported measures.
For most clinicians or groups participating in MIPS, quality measure reporting will count toward 60 percent of the MIPS composite score.
Quick Tips to Prepare for Quality Reporting
- Determine how you are currently reporting quality to CMS. If you are successfully participating in PQRS, many of your current measures and reporting processes will carry over under MIPS.
- Access your PQRS Feedback and Quality and Resource and Use Reports to determine your current quality performance as measured by CMS. It may be a member of your team or staff who holds the login for your practice.
- Make sure you’re up to speed on your 2016 PQRS reporting.
- Determine if QCDR quality reporting or another reporting mechanism is appropriate for you.
- Become familiar with the quality measures most applicable to your practice and patient population.
- Determine if you are participating in an APM. If you are participating in Track 1 of the Medicare Shared Savings Program, the Next Generation Accountable Care Organization, or another Medicare APM that is not an Advanced APM, you may only have to fulfill the quality requirements of your model and not report any additional MIPS quality data.