From the Washington Office: Navigating MIPS in 2017

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 (www.facs.org/qpp) has additional fact sheets and informational videos on the MIPS program.

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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.