The proposed rule for MACRA and the Merit-based Incentive Payment System (MIPS) program was released June 21, 2017. As expected, the program requiring the implementation of the new MIPS scoring system and incentives to move to alternative payment models (APMs) will continue.
This proposed rule represents a modification of the 2018 requirements as the program is phased in over a period of 4 years. The Department of Health and Human Services has limited ability to change the requirements of the program. The modifications in the proposed rule for 2018 are felt to fit within the framework of the legislation. Penalties and bonuses in the program were set by the MACRA legislation that fixed the sustainable growth rate and required the implementation of the MIPS program for traditional Medicare while providing additional money for growth of APMs. In this article, we will focus on the proposed rule’s effect on MIPS.
Recall that the MIPS program introduced last year included four categories, each of which made up a percentage of the final score for the program. The four categories that make up the MIPS score include Quality (formerly the Physician Quality Reimbursement System), Improvement Activities, Advancing Care Information (formerly Meaningful Use), and Cost (formerly the value-based modifier).
The data for each of the MIPS year are collected 2 years prior to the implementation of the bonus or penalty. For example, data submitted for 2017 will impact payments for the 2019 payment year.
Cost category delayed for 1 more year
For 2018, the Centers for Medicare & Medicaid Services is proposing to delay for 1 more year the inclusion of the Cost portion of the MIPS program. The proposed rule does not include the options of limited participation that were allowed in 2017; instead, reporting periods for each of the categories are as follows: Quality: 12 months; Improvement Activities: 90 days; Advancing Care Information: 90 days; and Cost: Not required.
The proposed rule included a change in the lower threshold for those required to participate in the MIPS program. For 2018, those physicians with equal to or less than $90,000 in traditional Medicare reimbursements (Medicare Advantage patients are not counted in the calculation) or equal to or less than 200 patients in traditional Medicare are excluded from reporting requirements for MIPS.
Quality. The proposed rule offered no significant changes to the Quality category for reporting during 2018. Options to report as an individual or a group remain. Six measures can be reported for individuals electing to report, with a maximum 10 points per measure. The Group Practice Reporting Option must again be elected by a group and require that a group sign up for the group reporting option. (If you intend to report as a group, you will need to monitor the sign-up deadlines put forth in the final rule once released).
MIPS Scoring Component Percentages
|Performance Category||2019 MIPS Payment Year||2020 MIPS Payment Year +/- 5%||2021 MIPS Payment Year +/- 7% – 9%|
|Advancing Care Information*||25%||25%||25%|
|* A MIPS-eligible clinician who cannot fulfill the Immunization Registry Reporting Measure may earn 5% for each public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under the performance score.||Source: Adapted from the Centers for Medicare & Medicaid Services information by Ray Painter MD and Mark Painter|
Reporting methods remain the same. CMS has reserved the right to remove measures from the final rule based on the number of providers successfully reporting the measures. CMS may also add measures to the list if they are approved. Final measures and reporting methods allowed for each measure will be released with the final rule by Nov. 1, 2017.
Carefully review the measures available and method of reporting when the final rule is released. The method of reporting each measure and the measures projected to be reported by urologists are included in a table.
Improvement Activities. The 90-day reporting period for Clinical Practice Improvement Activities will be reported to CMS via attestation for 2018, with no changes from current-year scoring. We encourage you to to review our previous articles (www.urologytimes.com/urology-coding) about MIPS for further information on this category.
Advancing Care Information. One of the bigger moves within the proposed rule is the slowing of EHR certification requirements. This move appears to reflect a reaction to industry feedback. The proposed rule allows physician offices to continue to use systems certified to 2014 to qualify for the Advancing Care Information category. Those who are using 2015 certified technology will be awarded bonus points for the category in a nod to continuing to push the industry toward the development of interoperability.
There is a proposed change in scoring requiring e-prescribing and security measures to be attested to but are awarded 0 points. Other scoring adjustments will require broader use of the EHR technology to score higher.
CMS is proposing to allow virtual groups to form to leverage purchasing power to lower costs using technology, information technology assistance, and consulting services. Groups of 10 or fewer physicians will be allowed to become reporting groups without changing their tax ID. This new proposal sounds promising and will be explored further by many groups. We intend to provide more information on this option as we study it in more detail.
The 2017 option to report over a limited period leading up to 2018 and the further phase-in of the program next year lead us to recommend that eligible providers and groups that have not yet geared up to participate in the MIPS program start now. It is not too late. In fact, a strategy that targets a Q4 implementation of data participation in the three categories of Quality, Improvement Activities, and Advancing Care Information will allow the group to potentially qualify for bonus payments in both 2019 and 2020. Additionally, groups that at least report something in Q4 2017 will get an idea of how well they are complying to each selected reporting activity in time to make some changes in 2018 to increase the potential of success with MIPS for 2020.
MIPS Quality Measures Likely to be Reported by Urologists
|National Quality Forum Number||Quality Number||CMS E-Measure ID||Data Submission Method||Measure Title and Description|
|0389||102||129v7||Registry, EHR||Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients:
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
|0390||104||N/A||Registry||Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate CancerPercentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist)|
|0062||119||134v6||Registry, EHR||Diabetes: Medical Attention for Nephropathy:
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.
|0421||128||69v6||Claims, Registry, EHR, Web Interface||Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan:
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter
Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
|0239||023||N/A||Claims, Registry||Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
|0326||047||N/A||Claims, Registry||Care Plan:
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
|N/A||048||N/A||Claims, Registry||Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older:
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
|N/A||050||N/A||Claims, Registry||Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older:
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
|0419||130||68v7||Claims, Registry, EHR||Documentation of Current Medications in the Medical Record:
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|0420||131||N/A||Claims, Registry||Pain Assessment and Follow-Up:
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
|0028||226||138v6||Claims, Registry, EHR, Web Interface||Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
|N/A||317||22v6||Claims, Registry, EHR||Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented:
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated
|N/A||358||N/A||Registry||Patient-Centered Surgical Risk Assessment and Communication:
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
|N/A||374||50v6||Registry, EHR||Closing the Referral Loop: Receipt of Specialist Report:
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
|N/A||428||N/A||Registry||Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence:
Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines
|N/A||429||N/A||Registry||Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy:
Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse
|2152||431||N/A||Registry||Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling:
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
|N/A||432||N/A||Registry||Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair:
Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery
|N/A||433||N/A||Registry||Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair:
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery
|N/A||434||N/A||Registry||Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair:
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery
|N/A||TBD||645v1||EHR||Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy:
Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.
|Source: Adapted from the Centers for Medicare & Medicaid Services information by Ray Painter MD and Mark Painter|