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MIPS Update: Five Key Areas of Clarification on the 2018 Quality Payment Program

by Jerry Miller on August 15, 2018 at 9:52 AM


The sheer volume of information contained in the 2018 Quality Payment Program (QPP) can lend itself to perceived conflicts with what we thought the rules were as well as some confusion just based on their complexity. There are five key areas that are important to highlight:

  1. Excluded Providers

The parameters for excluding individuals for the 2018 Merit-based Incentive Payment System (MIPS) is one of the areas where some confusion exists. The parameters are clinicians with less than or equal to $90,000 in Part B allowed charges with the number of Part B beneficiaries being less than or equal to 200. The question is the relationship between the two. The final rule uses both “and” and “or” throughout the document, so which is it in this instance?

A query to Centers for Medicare and Medicaid Services (CMS) provided the answer. The thresholds are defined by both charges and volume. So, if you provided service to 300 Medicare patients and the allowed Medicare charges were only $65,000, you would be exempt from MIPS participation because you only exceeded one of the parameters.

Can you participate in MIPS even if you are exempt? The answer is yes, you can. However, you will be unable to receive a positive payment adjustment since you are exempt from MIPS.

  1. Improvement Activity

Another subject is buried in the complexity of the program: there is a 2018 improvement activity for participation in Maintenance of Certification (MOC) Part IV. Can a group composed of both MDs and DOs attest to this improvement activity since it is specific to MOC? Board-certified MDs are covered by MOC whereas board-certified DOs are covered by a different program, Osteopathic Continuous Certification (OCC).

At least for 2018, then, the answer is clear: as long as one National Provider Identifier under the group’s TIN performs an improvement activity for a continuous 90-day period, all members of the group will be given credit for the improvement activity.

  1. Registry or Claims-based

Another area of confusion surrounds a possible limitation on data submission methods based on how you are making your initial submission for the year. More specifically, submitting quality measures individually by claims limits you to reporting improvement activities on an individual basis for each eligible clinician.

A response from CMS indicates that for 2018 you can use multiple submission methods across the performance categories; however, you are limited to one submission method within a category of MIPS.

  1. ACO Participation

There have also been several different points of view concerning quality measure reporting by an Accountable Care Organization (ACO) in conjunction with other reporting methods. If your TIN is part of an ACO, can you also report by Qualified Clinical Data Registry (QCDR),or another method such as QR or claims, and then have CMS take the best score among the methods of reporting?

The answer from CMS is no. According to CMS, as a participant TIN of an ACO, the ACO would be responsible for reporting the quality component of the program. They will use the ACO score unless the ACO fails to submit. In those instances, the data from the QCDR reports will be accepted.

  1. Hospital-based Groups and Advancing Care Information for 2018 (formerly known as EHR Meaningful Use)

Finally, hospital-based clinicians have been exempt from reporting the Advancing Care Information (ACI) category of MIPS. A hospital-based clinician is defined as an individual clinician who furnishes 75 percent or more of his/her Medicare Part B-covered services in sites identified by place of service codes (21-hospital inpatient, 22-hospital on campus outpatient, or 23-ED). A hospital-based group practice is considered a TIN where 100 percent of the MIPS eligible clinicians meet the definition of hospital-based as individuals. If there is one clinician in the group (TIN) that does not meet the 75 percent threshold to be considered hospital-based, a group would lose its exemption from reporting the ACI category of MIPS.

Groups that use providers that are exclusive to the UCC or a single TIN for both their hospital-based practices and those outside the hospital, such as Urgent Care Center (UCC), need to realize they may not be exempt from ACI reporting.

To check the qualifying status of your TIN and each clinician in your group, go to https://qpp.cms.gov/participation-lookup.

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This post was written by Jerry Miller

Jerry Miller is the Director of Coding Services at Intermedix.