***RETIRED*** MIPS 2018 Guide

This article is intended to be a step-by-step guide on how to meet Medicare's Quality Payment Program MACRA/MIPS  requirements successfully in 2018, the second year of the program. 


1. Verify that you are eligible to participate in the program in the first place.

CMS has created a tool on their Quality Payment Program site which allows you to quickly search by your NPI to determine if you're required to submit MIPS data. The tool can be found here.

Even though you may have been expected to report PQRS and Meaningful Use to Medicare in the past AND even if you were expected to report MIPS last year (2017), you may not need to report for MIPS in 2018. The following types of ECs (Eligible Clinicians) are expected to report under MIPS-

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists

However, the following ECs are excluded  from MIPS reporting requirements-

  • Those who are in their first year of billing Medicare
  • Those who bill under the newly increased "Low Volume Threshold" 

If 2018 is the first year you're billing Medicare, you will not have to participate in MIPS until 2019.

The Low Volume Threshold has been increased from 2017! For 2018, if an Eligible Clinician billed  "fewer than 200 unique Medicare patients or under $90,000 in allowed amount charges billed in a year", they are excluded. (This is an increase from the 100 unique Medicare patients and $30,000 that excluded Eligible Clinicians from the program in 2017.) CMS will look at a prior years worth of claims data to determine if an EC is excluded based on this volume. They will use a period of 12 months, pushed back 4 months for claim processing and exclusion determination. For example, to determine if you are excluded from reporting MIPS in 2018, CMS will evaluate Medicare claims data from 09/01/2016-08/31/2017. This is an "either or" exclusion so you will be excluded if you fall under one or both of the thresholds. For example, an EC who billed $46,500 in charges to Medicare but only did so for 180 unique Medicare patients would not have to report MIPS. Similarly, an EC who saw 463 Medicare patients, but whose total billing only amounted to $76,800 would also be excluded from MIPS. 

If you are not an Eligible Clinician listed or if you are excluded based on either of the above mentioned reasons, you do not need to worry about submitting anything for MIPS participation in 2018. You do not have a chance to earn any incentives for submitting any data, and you will not see any reductions to your Medicare payments for lack of submitting data. (You may still want to read on for education about the program in future years, should you decide to begin billing Medicare or plan to increase Medicare billing.)


2. Choose your level of participation in MIPS- simply avoid payment reductions or attempt to earn a payment increase.

This year (2018) is the second year of the new Quality Payment Program. As such, CMS has allowed flexibility in the amount of data that ECs will submit for 2018 reporting, since it's still a fairly new program. You have two options at this point, which you should choose after careful consideration of several factors. Your two options are-

1. "Submit Something" to avoid the reduction in Medicare payments. If you submit nothing, you will see a 5% decrease in payment amounts from Medicare in 2020 for every procedure you bill to them. To avoid this, you will NOT have to complete all three sections of MIPS, but rather a minimum amount of effort in one of the three sections.

2. "Fully Participate" for a chance of payment increases from Medicare up to 5%. This would require you to submit anywhere from 90 days to a full year worth of data for the Promoting Interoperability/Advancing Care Information and Improvement Activities sections, and a FULL YEAR of data for the Quality section. 

Things to consider for your Return On Investment-

  • How much of my practice's income comes from Medicare?- Medicare is the only insurance company whose payments will be effected by MIPS participation. If Medicare is a small portion of your practice's income, the potential increase of 5% of that income might not be a very large incentive when compared to the program requirements. If this is the case, you might just want to do the minimum amount of effort just to avoid payment reductions. This allows you to still receive "full" payments from Medicare without jumping through all the hoops of the MIPS program.
  • Do I need new/updated software? If you want to fully participate in MIPS and have a chance at the payment increases, you will need a certified version of software. If you do not already own this (which we're happy to verify for you if you call/email support), this likely involves the purchase and use of a new ability or two from MacPractice. If you already have a certified version and have been meeting Meaningful Use, PQRS, and MIPS requirements in years past, you might want to fully participate and earn a small increase in Medicare payments since you're used to a lot of the MIPS requirements already. If you do not already have a certified version, you may decide that the cost of acquiring one is not worth the potential Medicare payment increase.
  • Do I need training/workflow additions or updates for my staff? If you want to fully participate in MIPS and have a chance at the payment increases, you need to meet all objectives and measures of each of the three sections, aiming to achieve the best score possible in each one. For example, your office may not be used to our Patient Portal ability, which is needed to meet Objectives of the Promoting Interoperability/Advancing Care Information section of MIPS. This requires you to create portal access accounts for your patients, export summaries of visits to them, and securely message them. These could very likely be new work flow additions to your office or require some training for your staff. If full participation would involve training, new work flows, etc., you may want to consider starting this year with the bare minimum and adding on more measures next year, as you have time to perfect new work flow.


3. Verify that you need/have a certified version of software.

If you chose the first option listed above and want to "submit something" simply to avoid Medicare payment cuts, you do NOT need a certified software to accomplish this. The minimum requirements of MIPS can be accomplished by successfully reporting the Quality section of MIPS via your Medicare claims or a Registry. 

If you chose the second option listed above and want to "fully participate" in the program for a chance at Medicare payment increases, you WILL need a certified version of software. Certified software is required for many aspects of Promoting Interoperability/Advancing Care Information reporting such as secure messaging to patients, submission of immunizations to state registries, exchange of clinical summaries with referring doctors, and exporting clinical summaries to your patients after each visit.

If you are unsure if you own our certified version of MacPractice, feel free to contact our Government Programs support department at 844-896-2262 or and we will be happy to verify. 


4. Choose the appropriate measures and submission methods for your practice.

For ECs who chose to "Submit Something" just to avoid payment reductions-

- The easiest way to do this is by successfully submitting data for the Quality section. To do this, use CMS' page to filter all possible measures by your Specialty Measure Set.  Clicking the name of the measure will give you a list of Data Submission Methods. For the easiest option here, you will want to find measures that have "Claims" listed. This is the easiest way to report and will not require any additional software features nor integration with outside registries, which often have costs per provider. From here, choose six (6) measures you'd like to track and report. You need to choose measures that apply to your scope of practice, the demographic of patients you treat, the problems you diagnose, and the care you provide. Once you've chosen your measures, navigate to CMS' Resources page and scroll down to the Quality header. Under this header you will find 5 sets of downloadable measure specifications. These will include the reporting code(s) (also called a G code or CPTII code) that you will need to add to your claims every time you have a qualifying encounter with a Medicare patient. MacPractice's Government Programs support team is happy to assist with this process if necessary; we can't choose measures for you but we're able to help you search for codes and make sure they are added to your MacPractice system and your Medicare claims successfully. If using our recommendation of Claims submission, know that CMS will track all of your reporting codes on their end and there will be no other submission of data after the end of the year. 

You could also choose to submit your Quality data via a Registry. Sometimes registries offer more measures for different specialties than Claims submission does. Know that registries are a purchased third party option; MacPractice is willing and able to assist with this to the best of our ability, however there may be things that only the registry can assist you with. For registry reporting, your first step (after choosing your 6 measures) is to find a registry to use. MacPractice will not directly integrate with any registry, however we are able to assist you with setting up custom forms, codes, and reports/exports that will allow you to simply upload your data to the registry after the year is over. In order for us to assist with this process, we will need to know what registry you've chosen to use as well as have access to the registry's file upload templates. Typically each registry wants similar data but in different formats, so the process of entering information into MacPractice will differ depending on how the registry requires the data to be extracted and uploaded. MacPractice assists with these on a case by case basis. Some registries we've worked with in the past that offer all existing Quality measures (not just speciality specific) include MDInteractive and MIPSWizard. 


For ECs who chose to "Fully Participate" for a chance at payment increases-

Full participation in MIPS requires completing all three sections, aiming for a perfect score in all three- Quality, Promoting Interoperability (PI) aka Advancing Care Information (ACI) and Improvement Activities (IAs).

Quality- You will need to choose six (6) Quality measures to report. ALL SIX MEASURES need to be reported using the same Data Submission Method. See instructions in the step above for Quality reporting.

Promoting Interoperability/Advancing Care Information- You will need to complete the measures of this section that are part of the Base Score. Using CMS' page, scroll down slightly and choose the second tab titled "2018 Promoting Interoperabiltiy Transition Objectives and Measures". This is the set of measures that you will meet using MacPractice in 2018, as MacPractice only offers a 2014 certified product for 2018 reporting.

Click the name of each Objective and you will see if they are part of the Base Score. All four of the Base Score Objectives need to be completed in order to earn any score in this PI/ACI section. Once all Base Score Objectives are complete, you will add to your PI/ACI section score by achieving the highest possible percentages in the remaining Objectives. MacPractice includes reports to run (in our Measure Calculation folder of reports) which will help you monitor your progress and see how well you are doing at meeting each Objective. Achieve the best percentages possible on these Objectives throughout the year. After the year is over, you will log in to the QPP site and report your numbers to CMS.

Improvement Activities- Depending on the size of your practice, you will need to choose 1-4 Improvement Activities. For practices with fewer than 15 ECs, choose two (2) medium weighted or one (1) high weighted IA to complete. For Practices with 15 or more ECs, choose four (4) Medium weighted or two (2) high weighted IAs to complete. It is up to your office how you complete these activities, as CMS does not have specific reports or expectations in place for how they are accomplished. However, you will want to have some sort of proof that these were done, should CMS ever audit you for your submission. Complete these activities throughout the year, for at least 90 consecutive days. After the year is over, you will log in to a site and report whch activites you completed to CMS.

5. Establish workflows and receive training if desired. MONITOR YOUR PROGRESS.

We can not stress enough how important it is to begin understanding MIPS early and to stay on track throughout the entire year. Much like Meaningful Use and PQRS program reporting in years past, an EC will never be successful at submitting MIPS without an understanding of the program, plans and work flows in place to achieve all objectives and measures, and someone making sure that all objectives are being met throughout the year. There are several time sensitive objectives of MIPS that need to be completed at the time of (or within a few days after) each office visit and claim. ECs can not expect to successfully participate in MIPS if they put off reporting and ask for assistance in the last quarter of the year. This simply does not leave enough time for understanding, compliance, training, and work flow changes.

MacPractice offers comprehensive training (purchased at an hourly rate) for all of the MIPS program, should you feel that this is necessary. For offices who have never had experience reporting PQRS, Meaningful Use, or MIPS, we highly recommend a couple of hours of training with one of our Certified Meaningful Use/MIPS Professionals to get you started on the right foot.

An important part of successful MIPS compliance is to monitor your progress as you go. As stated, you cannot expect to look at reports of your progress for the first time in November and be meeting all of the objectives of the program if you've never implemented them into daily office work flow. The highest scores in the MIPS program will be achieved by the ECs who run progress reports at least weekly, and immediately address any issues. 

6. Submit before the deadlines. 

Submission deadlines for all sections of MIPS are 03/01/2019. (*If using a registry for your Quality data submission, these often have earlier deadlines.*) This means that you will collect data all throughout the year and after 2018 is over, you have 3 whole months to submit your data to CMS via the QPP site. Data not submitted by this deadline will not be factored into your score, and you will be scored as if you did not do anything in 2018. We encourage submitting as soon as the year is over and the submission site is open; several offices that waited until the last minute to submit 2017 data unfortunately found issues with their submission site login credentials and were unable to submit data because they waited until the last week to try to do so.

When the time comes, MacPractice offers assistance with your attestation which will help you ensure that all data is submitted correctly, on time, and successfully. As part of this service, we also ensure that records of your submissions are retained, which will become necessary should you ever be audited for your submissions. 

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