MACRA Terms

Term/Acronym

Description

Definition

ACA

Affordable Care Act

The Patient Protection and Affordable Care Act, or ACA, was signed into law in 2010 and initiated comprehensive health insurance reforms aimed at improving health care access, cost and quality.

ACI

Advancing Care Information

Advancing Care Information (ACI) is a performance category within the Merit-Based Incentive Payment System (MIPS). This category is based on elements of the Electronic Health Record (EHR) Incentive Program (Meaningful Use) and awards eligible clinicians and groups points based on their use of Certified Electronic Health Record Technology (CEHRT). For the 2017 performance year/2019 payment year, ACI counts for 25% of the MIPS score for most eligible clinicians (ECs) and groups.

ACO

Accountable Care Organization

An Accountable Care Organization (ACO) is an innovative health care delivery model centered around coordinated care that aims to provide high quality care to patients and spend health care dollars responsibly. ACOs that achieve this aim share savings with CMS. For 2017, the Next Generation ACO Model is an approved Advanced Alternative Payment Model (APM).

Advanced APM

Advanced Alternative Payment Model

An Advanced Alternative Payment Model (APM) is a specific type of APM defined under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that requires participants to use certified electronic health record technology (CEHRT), provide payment for covered professional services based on quality measures comparable to those used under the Merit-Based Incentive Payment System (MIPS) and is either a Medical Home Model expanded under the Centers for Medicare and Medicaid Services (CMS) Innovation Center, or requires participating entities to bear more than a nominal amount of financial risk for monetary losses.

APM

Alternative Payment Model

An Alternative Payment Model (APM), one of two participation tracks created by MACRA, requires eligible clinicians to take on a higher level of financial risk for patient outcomes than participation in the traditional track (the Merit-Based Incentive Payment System, or MIPS). In return, Advanced APMs provide the opportunity to earn greater rewards.

CAHPS

Consumer Assessment of Health Plans Survey

A Medicare beneficiary satisfaction survey required by the Centers for Medicare and Medicaid Services (CMS). H-CAHPS is for hospitals and CAHPS for Physician Quality Reporting System (PQRS)/CAHPS for the Merit-Based Incentive Payment System (MIPS), formerly known as CG-CAHPS, is for physician groups (clinical groups).

Cardiac Bundled Payment Models

In December 2016, the Centers for Medicare and Medicaid Services (CMS) finalized episode payment models for acute myocardial infarction (AMI Model), coronary artery bypass graft (CABG model), and cardiac rehabilitation (CR Incentive Payment Model). These models are scheduled to begin on Jul. 1, 2017, in selected metropolitan statistical areas (MSAs) and run through Dec. 31, 2021. The AMI and CABG models will hold a hospital financially accountable for an episode of care running 90 days after discharge to incentivize care coordination. The CR Incentive Payment Model will provide additional retrospective payments to participating hospitals to increase the utilization of cardiac rehabilitation services.

CEHRT

Certified Electronic Health Record Technology

For electronic health records (EHR) to be considered certified EHR technology (CEHRT), they must meet certain standards and criteria established by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC). Eligible clinicians must use CEHRT in order to successfully participate in the EHR Incentive Program.

CHIP

Children’s Health Insurance Program

The Children's Health Insurance Program (CHIP) provides affordable health coverage to children whose families make too much money to qualify for Medicaid. CHIP provides access to care for many children who have cardiovascular conditions such as those suffering from congenital heart disease.

CMMI

Center for Medicare and Medicaid Innovation (Innovation Center)

The Center for Medicare and Medicaid Innovation (CMMI), also known as the Innovation Center, was created under the Patient Protection and Affordable Care Act (ACA) to test payment and delivery system models that have the potential to maintain or improve the quality of care in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while slowing rising costs.

CMS

Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) is a federal agency responsible for Medicare, Medicaid and the Children's Health Insurance Program (CHIP). CMS is responsible for implementing the Quality Payment Program (QPP), initiated under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

CMS Web Interface

The Centers for Medicare and Medicaid Services (CMS) Web Interface, also known as the GPRO Web Interface, is a secure internet-based application made available by CMS for reporting Physician Quality Reporting Program (PQRS) or Merit-Based Incentive Payment System (MIPS) group-level quality data. Many Medicare Accountable Care Organization (ACO) participants also report quality data through the CMS Web Interface. Registration with CMS is required in order to report via the Interface.

Cost

Cost, also known as Resource Use, is a performance category within the Merit-Based Incentive Payment System (MIPS). Cost measures eligible clinicians and groups on the resources used to treat attributed Medicare beneficiaries based on Medicare claims data and measures. Unlike the other MIPS categories, Cost requires no reporting by eligible clinicians and groups. For the 2017 performance year/2019 payment year, Cost will not be factored into the MIPS score, but will be included in future years.

CPS

Composite Performance Score

The Merit-Based Incentive Payment System (MIPS) composite performance score (CPS) factors in an eligible clinician's performance in the Quality, Advancing Care Information (ACI), Improvement Activities and Cost categories. In 2017, Quality accounts for 60% of the CPS, ACI accounts for 25% and Improvement Activities accounts for 15%. Cost will not be factored into the CPS for the 2017 performance year.

CQM

Clinical Quality Measure

Clinical quality measures (CQMs) help measures and track the quality of health care services provided by eligible professionals, eligible hospitals and critical access hospitals. Under the Merit-Based Incentive Payment System (MIPS), clinicians will be assessed based on performance against CQMs developed by the ACC, the American Heart Association and other stakeholders. Most of these measures will be familiar to clinicians as measures reported under the Physician Quality Reporting System (PQRS).

EC/EP

Eligible Clinician/Eligible Professional

Health care professionals and hospitals must meet the eligibility criteria defined by law in order to participate in and receive incentive payments for the Medicare quality reporting programs, i.e., Physician Quality Reporting System (PQRS) Value-Based Payment Modifier, Electronic Health Record (EHR) Incentive Program, Merit-Based Incentive Payment System (MIPS). The definition for an EP/EC may vary by program. Under MIPS, the Centers for Medicare and Medicaid Services (CMS) is beginning to use the term Eligible Clinician in place of Eligible Professional.

EHR Incentive Program

Electronic Health Record Incentive Program

The Electronic Health Record (EHR) Incentive Program encourages the use of health information technology. Under the program, qualified physicians must demonstrate "meaningful use" of EHR technology. The Advancing Care Information (ACI) category replaces the EHR Incentive Program under the Quality Payment Program (QPP).

FFS

Fee-For-Service

Fee-For-Service (FFS) is the primary physician payment model in the U.S. The FFS model revolves around quantity of services instead of the quality of care being provided. The Medicare Access and CHIP Reauthorization of 2015 (MACRA) shifts the payment model from volume to value.

High Priority Measure

A High Priority Measure is a Merit-Based Incentive Payment System (MIPS) quality measure that falls under one of the following domains: outcome, appropriate use, patient safety, efficiency, patient experience, care coordination. Under the MIPS Quality performance category, bonus points will be awarded to eligible clinicians and groups that report High Priority Measures.

Improvement Activities

Improvement Activities is a performance category within the Merit-Based Incentive Payment System (MIPS). This category is a new element of Medicare quality reporting introduced under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Eligible clinicians and groups are awarded points based on their participation in a menu of activities that contribute to improved patient care. For the 2017 performance year/2019 payment year, the Improvement Activities category counts toward 15% of the MIPS score for most eligible clinicians (ECs) and groups.

Low-Volume Threshold

Certain clinicians and groups may be exempt from the Merit-Based Incentive Payment System (MIPS) if they meet the Low-Volume Threshold. For the 2017 performance year/2019 payment year, the Low-Volume Threshold is defined as clinicians or groups that have $30,000 or less in Medicare Part B allowed charges and see 100 or fewer Medicare beneficiaries in a year.

MACRA

Medicare Access and CHIP Reauthorization Act of 2015

The Merit-Based Incentive Payment System, or MIPS, is one of two tracks under the Quality Payment Program (QPP). Most cardiovascular professionals will participate in MIPS, which bundles the Physician Quality Reporting System (PQRS), the Value Modifier (VM) and the Electronic Health Record (EHR) Incentive Program into one program. There are four categories under MIPS: Quality, Improvement Activities, Advancing Care Information (ACI) and Cost. Incentive payments are based on an eligible clinician’s (EC's) or group’s composite performance score in these categories.

MIPS

Merit-Based Incentive Payment System

The Merit-Based Incentive Payment System, or MIPS, is one of two tracks under the Quality Payment Program (QPP). Most cardiovascular professionals will participate in MIPS, which bundles the Physician Quality Reporting System (PQRS), the Value Modifier (VM) and the Electronic Health Record (EHR) Incentive Program into one program. There are four categories under MIPS: Quality, Improvement Activities, Advancing Care Information (ACI) and Cost. Incentive payments are based on an eligible clinician’s (EC's) or group’s composite performance score in these categories.

MU

Meaningful Use

Meaningful Use (MU) refers to the Medicare Electronic Health Record (EHR) Incentive Program, which requires eligible clinicians to demonstrate "meaningful use" of EHR technology. Under the Quality Payment Program (QPP), the EHR Incentive Program/MU is replaced with the Advancing Care Information (ACI) category.

Non-Patient Facing MIPS Eligible Clinicians

Eligible Clinicians who bill Medicare for 100 or fewer patient-facing services are considered to be Non-Patient Facing. These clinicians may be eligible for flexibility under the Merit-Based Incentive Payment System (MIPS).

NPI

National Provider Identifier

The National Provider Identifier (NPI), a unique, 10-digit identification number for covered health care providers, was established under the Health Insurance Portability and Accountability Act. The NPI is separate from the Tax Identification Number (TIN).

Partial QP

Partial Qualifying Advanced Payment Model Participant

A Partial Qualifying Advanced Payment Model (APM) Participant, or Partial QP, is a clinician who participates in an Advanced APM under the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP), but does not meet the Qualifying Participant (QP) thresholds to receive the incentive payment under the Advanced APM track. A Partial QP may elect to participate in the Merit-Based Incentive Payment System (MIPS) with flexible scoring, or may elect to not participate.

PFPMs

Physician-Focused Payment Models

Physician-focused payment models (PFPMs) are Alternative Payment Models (APMs) developed by physicians under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Physician-Focused Payment Model Technical Advisory Committee makes recommendations on PFPMs to the Secretary of the Department of Health and Human Services.

PFS

Physician Fee Schedule

The Physician Fee Schedule (PFS), released annually by the Centers for Medicare and Medicaid Services, establishes reimbursement rates for physicians' Medicare services.

PQRS

Physician Quality Reporting System

The Physician Quality Reporting System (PQRS) collects data on the quality of care provided to Medicare beneficiaries based on clinician performance against selected quality measures. The Quality category replaces PQRS under the Quality Payment Program (QPP).

PTAC

Physician-Focused Payment Technical Advisory Committee

The Physician-Focused Payment Technical Advisory Committee (PTAC), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and driven by physicians, makes recommendations to the Secretary of the Department of Health and Human Services regarding physician-focused payment models submitted by individuals and entities.

QCDR

Qualified Clinical Data Registry

A qualified clinical data registry (QCDR) is a reporting mechanism available for the Physician Quality Reporting System (PQRS) that began in 2014. A QCDR will complete the collection and submission of PQRS quality measures data on behalf of Eligible Professionals (EPs). A QCDR is a Centers for Medicare and Medicaid Services (CMS)-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. To be considered a QCDR for purposes of PQRS, an entity must self-nominate and successfully complete a qualification process. QCDR submissions are accepted for 2016 PQRS individual and group level reporting. QCDR submissions will also be accepted for reporting Merit-Based Incentive Payment System (MIPS) data.

QP

Qualifying Alternative Payment Model Participant

A Qualifying Alternative Payment Model (APM) Participant (QP), typically determined at the Advanced APM entity level rather than at the level of the individual eligible clinician (EC), must meet certain thresholds of patients or payment flowing through an Advanced APM. QPs are excluded from the Merit-Based Incentive Payment System (MIPS) and receive a 5% lump bonus.

QPP

Quality Payment Program

The Quality Payment Program (QPP) is a new Medicare physician payment system established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The program is comprised of two pathways in which clinicians will participate in order to receive Medicare payment: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The QPP provides incentives to clinicians and groups that provide high-quality value-based care to Medicare beneficiaries.

QRUR

Quality and Resource Use Report

Quality and Resource Use Reports (QRURs), released to every group practice and solo practitioner based on Taxpayer Identification Number (TIN), show how clinicians and groups perform on Quality and Cost measures. Reviewing this report is an important way to understand cost and quality performance in preparation for the Quality Payment Program (QPP).

Quality

Quality is a performance category under the Merit-Based Incentive Payment System (MIPS). The Quality category is based on elements of the Physician Quality Reporting System (PQRS) and requires eligible clinicians and groups to report quality measure data. Unlike PQRS, which was a pay-for-reporting system, eligible clinicians and groups will be awarded points based on their performance against measure benchmarks. For the 2017 performance/2019 payment year, Quality will count toward 60% of the MIPS score for most eligible clinicians (ECs) and groups.

SGR

Sustainable Growth Rate

The Sustainable Growth Rate (SGR) was a formula that determined Medicare reimbursement until 2015. Congress had to intervene numerous times to avoid significant payment cuts from going into effect as a result of the flawed formula. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) permanently repealed the SGR and established a framework for rewarding clinicians for value over volume.

sQRUR

Supplemental Quality and Resource Use Report

Supplemental Quality and Resource Use Reports (sQRURs), released to every group practice and solo practitioner are informational only and provide payment-standardized, risk-adjusted cost information on episodes of care provided to Medicare patients. Reviewing this report is an important way to become familiar with the episode-based resource use measurement that will impact clinicians' Quality Payment Program (QPP) score starting with the 2018 performance year.

TIN

Taxpayer Identification Number

A Taxpayer Identification Number (TIN) is a nine-digit number assigned by the Internal Revenue Service or Social Security Administration. Quality Resource Use Reports (QRURs) are released to every group practice and solo practitioner based on TIN. The TIN is separate from the National Provider Identifier (NPI).

VM

Value-Based Payment Modifier

The Value-Based Payment Modifier (VM) provides bonus payments or penalties to eligible professionals based on the quality and cost of care provided during a performance period. The VM is aligned with the reporting requirements of the Physician Quality Reporting System (PQRS). The Cost category replaces the VM under the Quality Payment Program (QPP).