Life Science Compliance Update

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May 24, 2016

Understanding the CMS Proposed Rule for the Medicare Access and CHIP Reauthorization (MACRA) and the Merit-Based Incentive Payment System (MIPS)

As we have reported, the Centers for Medicare and Medicaid Services (CMS) released its proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA). This is a significant rule with fundamental changes for Medicare. In our continuing coverage, we will provide a more detailed analysis of the regulation. Today, we look at the rule's content related to the Merit-based Incentive Payment System (MIPS).

As a refresher, the rule creates a two-track Quality Payment Program. The first is called the Merit-based Incentive Payment System (MIPS) consolidates components of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program. A second track involves alternative payment models (APM). Because of the high bar set to qualify for the APM track, CMS projects that only 30,000 to 90,000 clinicians will be in the APM track. An estimated 687,000 to 746,000 physicians will be in MIPS. The program will begin grading physicians in 2017 for changes in their payments starting 2019. You can learn more at one of the many CMS webinars listed here.

MACRA Background

Last year, Congress and President Obama approved a bipartisan bill for United States healthcare reform, the bill known as the "doc fix" bill, or "MACRA," which stands for Medicare Access and CHIP Reauthorization Act of 2015. MACRA repealed the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new pay-for-performance program – the Merit-Based Incentive Payment System (MIPS). MACRA fundamentally alters how the Medicare program pays for services, as well as how providers interact with Medicare.

MACRA provides for updates to the fee schedule of .5% from July 2015 through 2019, at which point services on the physician fee schedule will remain at the 2019 level and be adjusted based on a provider's participation in MIPS or a qualifying APM. After 2026, providers participating in a qualified APM will receive a .75% update and all others will receive a .25% update.

Instead of applying the typical "one size fits all approach," MACRA allows eligible professionals and eligible organizations to identify quality measures and then tailor the quality measures that best fit their individual practice and specialty. Eligible professionals are assessed only on the categories that apply to them, and the categories may be reweighted to compensate, as needed. Each year, the Secretary will establish a performance threshold based on the performance of all participating eligible professionals, who will be informed of how they performed in the prior period and what performance threshold they must meet to be eligible for incentive payments and to avoid penalties. Additionally, eligible professionals who scores fall into a high performance category will receive an additional bonus payment, and providers who make notable gains in performance will be rewarded.

Advancing Care Information Performance Category

The meaningful use of certified EHR technology, now known as advancing care information, is one of the four performance categories under the MIPS reported by eligible clinicians. CMS will continue to review and evaluate this performance category and seeks comments on future potential changes, including methods to increase the stringency of the advancing care information performance measures; how eligible clinicians could be potentially measured more directly on how the use of health IT contributes to the overall health of their patients; measures that would be needed within the advancing care information performance category and the other performance categories to develop a more patient-focused health IT program; and functionalities needed within certified EHR technology to develop a more patient-focused health IT program. Read more from CMS' perspective here.

CMS proposes to align the performance period for the advancing care information performance category to the proposed MIPS performance period of one full calendar year. Under this proposal, for the first year of MIPS, MIPS eligible clinicians would need to submit data based on a performance period starting January 1, 2017 and ending December 31, 2017. CMS states this proposal would reduce reporting burden and streamline requirements so that all performance categories have a common timeline for data submission.

CMS proposes to allow the submission of advancing care information performance category data through qualified registry, EHR, QCDR, attestation and CMS Web Interface submission methods. Regardless of data submission method, all MIPS eligible clinicians must follow the reporting requirements for the objectives and measures to meet the requirements of the advancing care information performance category.

CMS also proposes a group reporting mechanism for individual MIPS eligible clinicians to have their performance assessed as a group for all performance categories. Therefore, the data submission criteria for the advancing care information performance category would be the same when submitted at the individual and group level, but the data submitted would be aggregated for all MIPS eligible clinicians within the group practice.

CMS Proposed Data Submission Mechanisms for MIPS Eligible Clinicians Reporting Individually as a TIN/NPI

CMS Proposed Data Submission Mechanisms for Groups

CMS proposes that performance in the advancing care information performance category will comprise 25 percent of a MIPS eligible clinician's CPS for payment year 2019 and each year thereafter. CMS is proposing that that the score would be comprised of a score for participation and reporting, referred to as the "base score", and a score for performance at varying levels above the base score requirements, referred to as the "performance score". CMS is also proposing two variations of a scoring methodology for the base score, a primary (table 6 in rule) and an alternative proposal (table 7). For either proposal, the base score would account for 50 percent, out of a total of 100 percent, of the advancing care information performance category score.

CMS proposes that a MIPS eligible clinician would earn additional points above the base score for performance on eight associated measures under the Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives. The eight associated measures would each be assigned a total of 10 possible points. An eligible clinician has the potential to earn a performance score of up to 80 percent. The combination of the performance score with the base score would provide a total score that is more than the total possible 100 percent for the advancing care information performance category. CMS states this allows flexibility for eligible clinicians to focus on measures that are most relevant to their practice to achieve the maximum performance score.

CMS proposes to sum the base score, performance score and the potential Public Health and Clinical Data Registry Reporting bonus point to obtain the overall score for this performance category. If the sum of the MIPS eligible clinician's total score is greater than 100 percent, CMS would apply an advancing care information performance category score of 100 percent. The total percentage score (out of 100) would then be applied to the 25 points allocated for the advancing care information performance category. Extreme and uncontrollable circumstances, such as natural disasters in which an EHR or practice buildings are destroyed, can prevent a MIPS eligible clinician to be able to access certified EHR technology.

CMS Base Score Primary Proposal Advancing Care Information Objective and Measure Reporting

CMS total Estimate Burden for Advancing Care Information Performance Category Data Submissions

Clinical Practice Improvement Activity (CPIA) Category

This is a new area so it may be advisable to spend extra time learning about the category. There will be a June 22, 2016 CMS webinar (details here). The agency proposes baseline requirements for the CPIA category and plans to revise the requirements in future years to have more stringent requirements with a focus on continuous improvement over time. CMS discusses two themes emerged in the comments it received in response to the MIPS and APMs RFI. First, that all subcategories should be weighted equally and that MIPS eligible clinicians or groups should be able to select from any subcategory most applicable to them. Second, commenters supported inclusion of a diverse set of activities. CMS states they took these recommendations into consideration for the proposal.

CMS proposes that the CPIA performance will account for 15 percent of the overall score. A MIPS eligible clinician or group that is certified as a patient-centered medical home or comparable specialty practice for a specific performance period must be given the highest potential score for the CPIA performance category for the performance period. CMS proposes a patient-centered medical home (PCMH) will be recognized if it is a nationally recognized accredited PCMH, a Medicaid Medical Home Model, or a Medical Home Model. See full list of proposed CPIA activities and their scoring weights.

MACRA also provides that MIPS eligible clinicians or groups who are participating in an APM for a performance period must earn at least one half of the highest potential score for the CPIA performance category for the performance period. CMS notes that consistent with the statute, a MIPS eligible clinician or group is not required to perform activities in each CPIA subcategory or participate in an APM to achieve the highest potential score for the CPIA performance category. In addition, if a MIPS eligible clinician or group fails to report on an applicable CPIA that is required to be reported, they will receive the lowest potential score applicable to that CPIA.

CMS proposes that for the first year only, all MIPS eligible clinicians and groups, or third party entities such as health IT vendors, QCDRs and qualified registries that submit for an eligible clinician or group, must designate a yes/no response for activities on the CPIA Inventory. The MIPS eligible clinicians or groups will certify all CPIAs that have been performed, and the third party entity submits on their behalf.

MACRA mandates a differentially weighted scoring model by requiring 100 percent of the potential score in the CPIA performance category for PCMH participants, and a minimum 50 percent score for APM participants. For additional activities, CMS proposes a differentially weighted model for the CPIA category with two categories: medium and high. CMS states this allows flexible scoring for the measures, which is important since they consider these measures as being undefined activities; CPIA activities are not nationally recognized and there is no entity equivalent to the NQF for CPIA measures.

CMS requests comments on this proposal, including criteria or factors it should take into consideration to determine whether to weight an activity as medium or high. CMS reminds commenters that a good guide in determining if a commenter believes a CPIA should be medium or high is considering how that activity compares with a PCMH, which achieves the highest possible CPIA score.

CMS proposes that the highest potential score of 100 percent is equivalent to a CPIA performance score of 60 points and assigns 10 points for a medium-level activity and 20 points for a high-level activity. To achieve the highest potential score of 100 percent, CMS requires submission of three high-weighted CPIAs (20 points each) or six medium-weighted CPIAs (10 points each), or a combination of CPIAs to achieve a total of 60 points. MIPS eligible clinicians or groups that select less than the designated number of CPIAs to achieve 60 points will receive partial credit based on the weighting of the CPIA selected.

CMS discusses the following exception for MIPS eligible clinicians and groups, including eligible clinicians or groups that are small groups (less than 15 clinicians), located in rural areas or geographic HPSAs, or non-patient-facing MIPS eligible clinicians, are required to submit two CPIAs (either medium or high) to obtain a score of 100 percent. To obtain a score of 50 percent, only one CPIA (either medium or high) is required. Or, eligible clinicians or groups that are participating in an APM will receive 50 percent of the total CPIA score (30 points). To achieve 100 percent of the total CPIA score, eligible clinicians or groups will need to select additional CPIAs for an additional 30 points to reach the 60 point score, the CPIA highest score.

CMS proposes that MIPS eligible clinicians or groups must perform CPIAs for at least 90 days during the performance period for CPIA credit. CMS states that additional clarifications for how some activities meet the 90-day rule or if additional time is required are included in the description of the activity in the CPIA inventory (Table H of the Appendix).

The CPIA performance category must include the following subcategories: Expanded practice access; Population management; Care coordination; Beneficiary engagement; Patient safety and practice assessment; and Participation in an APM. The statute also provides the Secretary the discretion to specify additional subcategories and in the MIPS and APMs RFI, CMS requested recommendations on the following potential new subcategories: Promoting health equity and continuity; Social and community involvement; Achieving health equity; Emergency preparedness and response; and Integration of primary care and behavioral health. For the first year of MIPS, in addition to the CPIA subcategories required in the statute, CMS proposes adding Achieving health equity; Integrated behavioral and mental health; and Emergency preparedness and response. CMS seeks comments, including potential CPIA activities, on two additional subcategories for future consideration: Promoting health equity and continuity; and Social and community involvement.

CMS also discusses the process they used to ensure that the initial CPIA Inventory is inclusive of activities that correspond with the statutory intent. CMS proposes to consider the addition of a new subcategory or activity to the CPIA Inventory when the following criteria are met:

  • The subcategory represents an area that could highlight improved beneficiary health outcomes, patient engagement, and safety based on evidence.
  • The new subcategory has a designated number of activities that meet the criteria for a CPIA activity and cannot be classified under the existing subcategories.
  • The newly identified subcategory would contribute to improvement in patient care or improvement in performance on quality measures and resource use performance categories.

CMS plans to develop a call for measures and activities for future years where stakeholders may recommend activities for inclusion in the CPIA Inventory. CMS also plans to develop a process and establish criteria to remove or add new activities to CPIA.

Consistent with scoring for the quality and resource use categories, CMS proposes to calculate the CPIA category score as the sum of points earned on CPIAs divided by the maximum possible 60 points. The score would be capped at 100 percent. Table 24 in the proposed rule provides an example of CPIA category score for an eligible clinician.

Quality Performance Category

The Quality performance category (compared to PQRS) will account for 30 percent of the composite performance score (CPS). However, for the first and second years of MIPS, the percentage of the CPS applicable for the quality performance category will be increased so that the total percentage points of the increase equals the total number of percentage points by which the percentage applied for the resource use performance category is less than 30 percent. For the first year, not more than 10 percent of the CPS will be based on the resource use category and for the second year, not more than 15 percent of the CPS will be based on the resource use category. Starting on page 773 of the rule, CMS lists proposed quality measures for MIPS reporting in 2017.

We have broken out proposed quality measures:

List of Proposed Reportable Quality Measures

List of Proposed Cross Cutting Measures

List of Measures with Significant Changes for MIPS

List of New Measures

CMS proposes for payment years 2019 and 2020, the quality performance category will account for 50 percent and 45 percent, respectively, of the CPS. For the third and future years, 30 percent of the MIPS CPS will be based on performance on the quality performance category. CMS states that under their proposed scoring policy, a MIPS eligible clinician or group that reports on all required measures could potentially obtain the highest score possible within the performance category, presuming it performed well on all the measures reported. A MIPS eligible clinician or group that does not meet the reporting threshold would receive a zero score for the unreported items in the category which would prevent it from obtaining the highest possible score.

CMS seeks comments on its proposal to allow reporting of specialty-specific measure sets to meet the submission criteria for the quality performance category, including those measure sets with fewer than six measures, including one cross-cutting measure and one outcome measure, or if an outcome measure is not available another high priority measure. Specifically, CMS seeks comments on whether it is appropriate to allow reporting of a measure set at the subspecialty level to meet the submission criteria, since reporting at the subspecialty level could require reporting on fewer measures. Additionally, should CMS only consider reporting up to six measures at the higher overall specialty level to satisfy the submission criteria?

MACRA requires the Secretary to use rulemaking to establish an annual list of quality measures from which MIPS eligible clinicians may choose for purposes of their assessment for a performance period. The annual list of quality measures must be published in the Federal Register no later than November 1 of the year prior to the first day of a performance period and updates to the annual list must also be published in the Federal Register no later than November 1of the year prior to the first day of each subsequent performance period. In the first year of MIPS, CMS proposes to maintain a majority of previously implemented PQRS measures for inclusion in the annual list of quality measures.

Additionally, the Secretary must solicit a "Call for Quality Measures" each year and must request that eligible clinician organizations and other relevant stakeholders identify and submit quality measures to be considered in the annual list of quality measures, as well as updates to the measures. CMS will accept quality measures at any time but only measures submitted before June 1 of each year will be considered for inclusion in the annual list of quality measures for the performance period beginning 2 years after the measure is submitted. For example, a measure submitted prior to June 1, 2016 would be considered for inclusion in the 2018 performance period.

To score this category, one to ten points would be assigned to each measure, based on a clinician's performance compared to benchmarks. For each measure, a case minimum would have to be met for a clinician to receive a score. Zero points are awarded if the clinician fails to submit data on a required measure. If data submission is completed, the clinician would either receive a score or the measure would not be counted because the case minimum is not met or for another reason the measure cannot be scored. The total domain score would be the sum of all the points assigned for the scored measures plus bonus points (up to a cap) divided by the sum of total possible points. In general, clinicians would be required to submit six measures and would also be scored on up to three population-based measures calculated from administrative claims data. The total possible points for the quality performance category would be 90 points.

Unlike PQRS, which requires eligible professionals to meet all the criteria or be subject to a penalty, under the MIPS CMS proposes to move away from the "all or nothing" scoring approach. Clinicians would be given some amount of points for all measures that are successfully reported. If the case minimum is not met for a measure, that measure would not be included in the score. But CMS wants to discourage clinicians who are able to submit measures that can be scored from continuing to submit the same measures year after year that cannot be scored because they do not meet the case minimum. Comments are sought on safeguards to minimize gaming attempts.

To calculate the quality performance category score, a methodology is proposed. The sum of the weighted points assigned to measures required by the quality performance category criteria would be added to any bonus points earned. That total would be divided by the weighted sum of total possible points to equal the quality performance category score. CMS notes that if an eligible clinician reports more than the minimum number of measures, it would include in the category total only the scores for the measures with the highest assigned points. This would allow eligible clinicians to gain experience reporting measures before they are included in the score.

Resource Use Performance Category

MACRA requires the development of care episode and patient condition groups, and classification codes. In addition, care episode and patient condition groups are to account for a target of an estimated one-half of expenditures under Parts A and B, with the target increasing over time as appropriate. To facilitate the attribution of patients and episodes to one or more clinicians, MACRA requires the development of patient relationship categories and codes that define and distinguish the relationship and responsibility of a clinician with a patient.

On or after January 1, 2018, claims for services furnished by a physician or applicable practitioner will include applicable codes established for care episode groups, patient condition groups, and patient relationship codes. Claims will also include the NPI of the ordering physician or applicable practitioner. This information will be used to attribute patients to one or more physicians or applicable practitioners and determine resource use. For measuring resource use, the Secretary will use per patient total allowed charges for all services under Parts A and B, and if the Secretary determines appropriate Part D.

The resource use performance category will account for not more that 10 percent of the CPS for the first MIPS payment year (2019) and not more than 15 percent for the second MIPS payment year (2020). CMS proposes for payment years 2019 and 2020, the resource use performance category will account for 10 percent and 15 percent, respectively, of the CPS. For the third and future years, 30 percent of the CPS will be based on the resource use performance category.

CMS proposes 41 clinical conditions and treatment episode-based measures for the 2017 MIPS performance period: 34 are Method A measures and 7 are Method B measures. The broad clinical topics for the episode-based measures include breast cancer, and diseases related to cardiovascular, cerebrovascular, gastrointestinal, genitourinary, infectious, neurologic, musculoskeletal, respiratory and vascular conditions. The Method B measures also include an ophthalmology measure related to lens and cataract procedures. Although CMS is proposing 41 measures, because these measures have never been used for payment purposes, CMS states they may choose to only include a subset of these measures in the final rule.

CMS Resource Use Performance Category Example

Regarding attribution, CMS proposes that acute condition episodes would be attributed to all MIPS eligible clinicians that bill at least 30 percent of inpatient evaluation and management visits during the initial treatment or "trigger event" that opens the episode. CMS states these visits are directly related to the management of the acute condition and that eligible clinicians who bill at least 30 percent of the IP E&M visits are likely to have been responsible for the oversight of the care during the episode. Using this methodology, CMS notes it is possible that more than one MIPS eligible clinician will be attributed to a single episode. CMS proposes that procedural episodes would be attributed to all MIPS eligible clinicians that bill a Part B claim with a trigger code during the trigger event of the episode.

CMS proposes that any Part B claim or line item during the trigger event with the episode's triggering procedure code is used for attribution. If more than one eligible clinician bills a triggering claim, the episode is attributed to each of the eligible clinicians. If co-surgeons bill the triggering claim, the episode is attributed to each MIPS eligible clinician. If only an assistant surgeon bills the triggering claim, the episode is attributed to the assistant surgeon or the group. If an episode does not have a concurrent Part B claim with a trigger code for the episode, then the episode is not attributed to any eligible clinician. Additionally, CMS proposes to use the minimum of 20 cases for all episode-based measures and not to include any measures that do not have average moderate reliability at 20 episodes.

To score measures in the resource use performance category would be similar to scoring of measures in the quality performance category: benchmarks would be calculated as deciles and from 1 to 10 achievement points awarded depending on where the clinician's performance falls within the benchmarks. The measure scores would be averaged and then divided by the total number of potential points to determine the clinician's performance category score.


CMS proposes to establish a scoring standard for MIPS eligible clinicians participating in certain types of APMs that will reduce participant reporting burden by eliminating the need for such APM eligible clinicians to submit data for both MIPS and their respective APMs. CMS proposes to use the APM scoring standard for MIPs eligible clinicians in APM Entity groups participating in certain APMs that meet the criteria.

CMS proposes that the APM scoring standard would not apply to MIPS eligible clinicians participating in APMs that are not MIPS APMs. CMS notes that since the criteria for the identification of MIPS APMs are independent of the criteria for Advanced APM determinations, a MIPS APM may or may not also be an Advanced APM. Based on the proposed policy, the APM scoring standard would not apply to MIPS eligible clinicians involved in APMs that include facilities as participants (such as the Comprehensive Care for Joint Replacement Model) and to APMs that do not base payment on cost/utilization and quality measures (such as the Accountable Health Communities Model).

The proposed APM scoring standards would still require MIPS eligible clinicians to report certain data under MIPS regardless of whether they ultimately become Qualifying APM Participants (QPs) or Partial Qualifying APM Participants (Partial QPs) through their participation in Advanced APMs. Although QPs and Partial QPs who elect not to participate in MIPS would be excluded from MIPS payment adjustments, CMS believes for operational and administrative reasons, it is necessary to treat these eligible clinicians as MIPS eligible clinicians unless and until the QP or Partial QP determination is made.

CMS proposes that the performance period for MIPS eligible clinicians participating in MIPS APMs would generally match the applicable calendar year performance period proposed for MIPS. For a new MIPS APM for which the first APM performance period begins after the start of the corresponding MIPS performance period, CMS proposes the participating MIPS eligible clinicians would submit data to the MIPS in the first MIPS performance period for the APM either as individual MIPS eligible clinicians or as a group, and report to CMS using the APM scoring standard for subsequent MIPS performance periods.

CMS states that the proposed APM scoring standard is similar to the proposed group assessment under MIPS except for the following:

  • Depending on the terms and conditions of the MIPS APM, an APM Entity could be comprised of a sole MIPS eligible clinician (for example, a physician practice with only one eligible clinician could be considered an APM Entity);
  • The APM Entity could include more than one unique TIN, as long as the MIPS eligible clinicians are identified as participants in the APM by their unique APM participant identifiers; and
  • The composition of the APM Entity group could include APM participant identifiers with TIN/NPI combinations such that some MIPS eligible clinicians in a TIN are APM participants and other MIPS eligible clinicians in the same TIN are not APM participants.

CMS proposes that depending on the type of MIPS APM, the weights associated with performance categories may be different than the generally applicable weights for MIPS eligible clinicians. CMS proposes that under the APM scoring standard, the weight for the resource use performance category will be zero. CMS also proposes that for certain APMs, the weight for the quality performance category will be zero for the 2019 payment year. Neither the APM Entity nor the eligible clinicians would need to report quality performance data. CMS would redistribute the weights for the quality and resource use performance categories to the CPIA and advancing care information performance categories to maintain a CPS of 100 percent.

CMS plans to establish and maintain an APM participant database that will include all of the MIPS eligible clinicians who are part of the APM Entity. CMS proposes that each APM Entity would be identified in the MIPS program by a unique APM Entity identifier, and that the unique APM participant identifier for a MIPS eligible clinician would be a combination of four identifiers, including (1) APM identifier (established by CMS); (2) APM Entity identifier (established by CMS); (3) the eligible clinician's billing TIN; and (4) NPI.

CMS APM Entity Submission Method for Each MIPS Performance Category

Physician Compare

CMS reviews the requirements regarding public reporting on the Physician Compare website under MACRA and the Affordable Care Act, and in accordance with these requirements proposes for each MIPS eligible clinician, composite scores and performance by category; and aggregate information on the range of MIPS composite scores and range of performance by category. These data would be added on the profile pages or in the downloadable database, as technically feasible. CMS proposes that statistical testing, consumer testing, and consultation with the Physician Compare Technical Expert Panel would determine how and where the data are reported. CMS seeks comments on the advisability and feasibility of including data voluntarily reported by EPs and groups not subject to the MIPS adjustment.

All CPIA category data would be available for public reporting on Physician Compare. CMS proposes to identify a subset of data that meet public reporting standards. An indicator that a clinician has successfully met CPIA category requirements may be posted. Because CPIA is a new category CMS intends to employ consumer testing as well as statistical testing in identifying data for public reporting. With respect to the advancing care information category, CMS proposes to expand the information provided on Physician Compare regarding clinicians' performance on measures of meaningful use. It says this type of information resonates with consumers.

MIPS Exclusions and Payments

CMS proposes that a new Medicare-enrolled eligible clinician is defined as a professional who first becomes a Medicare-enrolled eligible clinician within the PECOS during the performance period for a year and who has not previously submitted claims as a Medicare-enrolled eligible clinician either as an individual, an entity, or a part of a physician group or under a different billing number or tax identifier. CMS also proposes that in no case would a MIPS adjustment factor apply to items and services provided by new Medicare-enrolled eligible clinicians. Additionally, partially-qualifying APM participants will have the option to elect whether or not to report under MIPS, which determines whether or not they will be subject to MIPS adjustments.

In terms of thresholds, CMS proposes to define MIPS eligible clinicians or groups who do not exceed the low-volume threshold as an individual MIPS eligible clinician or group who, during the performance period, has Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Part B-enrolled Medicare beneficiaries. CMS states that this threshold excludes MIPS eligible clinicians who do not have a substantial quantity of interactions with Medicare beneficiaries or furnish high cost services. CMS also notes it considered using items and services instead of the number of Part B-enrolled individuals but there were only small differences between the two methods.

To define an eligible clinician, CMS proposes to include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetist, and a group that includes such professionals. CMS anticipates that eligible clinicians who are not MIPS eligible professionals during the first two years of the program, such as physical and occupational therapists and others that have been reporting quality measures under the PQRS, will want to have the ability to continue to report and gain experience under MIPS.

CMS further proposes to define a non-patient-facing MIPS eligible clinician for MIPS as an individual MIPS eligible clinician or group that bills 25 or fewer patient-facing encounters during a performance period. CMS considers a patient-facing encounter to include general office visits, outpatient visits, surgical procedure codes, and telehealth services; it intends to publish the proposed list of face-to-face encounter codes on a CMS website (similar to the list of face-to-face encounter codes for PQRS). CMS selected this threshold based on analysis of non-patient-facing HCPCS codes billed by MIPS eligible clinicians, which indicated that the majority of clinicians enrolled in specialties such as anesthesiology, nuclear medicine and pathology, were identified as non-patient facing.

The MIPS adjustment factor would be applied to Part B payments as a percentage adjustment for a payment year. Part B amounts otherwise payable would be multiplied by 1 plus the MIPS adjustment percentage. Furthermore, the statute provides that the MIPS adjustment factor be calculated so that eligible clinicians with a CPS at or above the performance threshold receive a zero or positive adjustment factor. The adjustment of 0 percent is assigned for a CPS at the performance threshold and a maximum adjustment factor of the "applicable percent" (4 percent for 2019) is assigned for a CPS of 100 percent; a linear sliding scale determines the adjustment for CPS that falls between these amounts. For eligible clinicians with a CPS below the performance threshold, the MIPS adjustment factor is negative, with the maximum negative adjustment of the applicable percent assigned to a CPS equal to or greater than zero but not greater than one-fourth of the performance threshold. A linear sliding scale between the CPS of zero maximum negative adjustment and the threshold adjustment of zero determines the negative adjustment for a CPS between these amounts. It was unclear if CMS would pursue such a linear structure, or have the majority of MIPS participants in a neutral position, only adjusting the extremes at the positive and negative ends of the spectrum.

CMS Illustrative Example of MIPS Adjustment Factors Based on Composite Performance Scores (CPS)


CMS Weights by Performance Category


*The weight for advancing care information could decrease (not below 15 percent) if the Secretary estimates that the proportion of physicians who are meaningful EHR users is 75 percent or greater. The remaining weight would then be reallocated to one or more of the other performance categories.


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