From the Washington Office

From the Washington Office: Navigating MIPS in 2017


2017 is here and the new Merit-based Incentive Payment System (MIPS) is now in effect. MIPS has taken a number of steps to streamline reporting and make it easier to avoid penalties and achieve positive updates. However, over time penalties for non-participation or poor performance will grow. Therefore, it is critically important that all surgeons make a plan for how they can best participate in order to succeed. Knowing what options are available is vital to navigating the new reporting requirements and achieving the best possible financial outcome.

Background on MIPS and its components

MIPS began measuring performance in January 2017. The data reported in 2017 will be used to adjust payments in 2019. MIPS took the Physician Quality Reporting System (PQRS), the Value Based Modifier (VM), and the EHR Incentive Program commonly referred to as Meaningful Use (EHR-MU), added a new component that provides credit for Improvement Activities and combined them to derive a composite MIPS Final Score. The components of the Final Score are known as Quality, (formerly PQRS), Cost, (formerly VM), Advancing Care Information (ACI), (formerly EHR-MU), and Improvement Activities. The weights for the individual components of the final score for the first year of the MIPS program are represented in the chart above.

Though CMS has chosen not to provide any weight to the Cost component during the first year of the program, those who report Quality data will receive feedback reports on their performance in the Cost component.

Dr. Patrick V. Bailey
Dr. Patrick V. Bailey

2017: The transition year

The Centers for Medicare & Medicaid Services (CMS) designated 2017 as a transition year and has provided a clear pathway to avoid penalties. In addition, CMS has reduced the reporting requirements in 2017 for those who wish to fully participate in preparation for the future or those practices whose goal is the achievement of a positive payment update. It is important to note that the funds available for positive payment updates are derived from the penalties assessed on those who choose NOT to participate. Accordingly, by making it easier to avoid penalties in the first year, CMS has also reduced the amount of funds available for positive incentives.

Participating to avoid penalties

For 2017, CMS instituted options to allow surgeons to “Pick Your Pace” for participation in MIPS. Those who choose not to participate at any level will receive the full negative payment adjustment of 4% in 2019. However, it is noteworthy that a 4% negative payment adjustment is less than half of the negative adjustments associated with the PQRS, VM, and Meaningful Use programs in 2016.

To avoid the 4% penalty, CMS only requires that surgeons test their ability to report data in any of three reporting components, namely Quality, ACI or Improvement Activities. Information for the Cost component is derived automatically and has no reporting requirement. To avoid a penalty, surgeons must simply report one Quality measure for a single patient, attest to participating in an approved Improvement Activity for at least 90 consecutive days or complete the Base score requirements for ACI.

Participating to prepare for future success

Those who wish to attempt to achieve a higher score must report data for 50% of all patients seen (for ALL payors) for any consecutive 90 day period. Accordingly, one could begin as late as October 2, 2017. How data is reported depends upon the circumstances of an individual’s practice as there are multiple methods (electronic health record, registry, or qualified clinical data registry) for submitting data to CMS. It should be noted that data can also be submitted either on an individual basis or as a group.

Reporting pathway toward potentially receiving a positive payment update: Reporting for Quality

To receive the full potential Quality score, data must be submitted for 50% of all patients seen (for ALL payors) for any consecutive 90 day period on a minimum of 6 measures including one Outcome measure. Alternatively, one can choose to use a specialty measure set to report on 50% of all patients seen (for ALL payors) for any consecutive 90 day period. Those who do meet the reporting requirement and perform well on the measures will receive up to 60 points toward their MIPS Final Score. For those who intend to simply avoid penalties for the first year of the MIPS program, reporting a single measure for a single patient will earn the 3 points necessary to meet the threshold prescribed by CMS to avoid a penalty.

Reporting for ACI

The ACI component is worth 25 percent of the MIPS Final Score. The assessment for ACI is a composite score composed of two parts, a Base score and a Performance score. To receive credit for the ACI component 2017, one must have either 2014 or 2015 Edition CEHRT.

The Base score is an “all-or-nothing” threshold and accounts for 50 percent of the total score for the ACI component. Achievement of the Base score is required before any score can be accrued for the Performance portion. Achieving the Base score is also one of the options prescribed by CMS sufficient to avoid MIPS penalties in the first year and if the Base Score is achieved, one will not receive a penalty for 2017. The ACI measures are intended to ensure that certified EHRs are being used for core tasks such as providing patients with online access to their medical records, exchanging health information with patients and other providers, electronic prescribing and protecting sensitive patient health information.
Once all of the measures for the Base score have been met, clinicians are eligible to receive credit for performance on both a subset of the Base score measures and on a set of additional optional measures. Bonus points are also available by reporting certain Improvement Activities via a certified EHR.

Reporting for Improvement Activities

While the Improvement Activities (IA) is a new category, surgeons are familiar with many of the activities including maintenance of certification, use of the ACS Surgical Risk Calculator, participation in a QCDR and registry with their state’s prescription drug monitoring program. Each activity is assigned a point value of either 20 points (high value) or 10 points (medium value). The reporting requirement for the IA is fulfilled by simple attestation via either a registry, qualified clinical data registry, or a portal on the CMS website. To receive full credit, most surgeons must select and attest to having completed between two and four activities for a total of 40 points. Some surgeons in rural or small practices will only need to complete one high value or two medium value activities to achieve full credit. Those who fulfill the requirement will receive 15 points toward the MIPS Final Score. For those whose goal is simply to avoid a penalty in the first reporting year of MIPS, reporting a single activity for 90 days is enough to avoid any MIPS penalties for 2017

For those seeking further information, the ACS website ( has additional fact sheets and informational videos on the MIPS program.

Until next month …

Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.

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