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2018 MPFS Proposed Rule Eases Reporting Criteria

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  • July 19, 2017
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2018 MPFS Proposed Rule Eases Reporting Criteria

There’s a definite theme seen throughout the 2018 Medicare Physician Fee Schedule (MPFS) proposed rule: The Merit-based Incentive Payment System (MIPS) is referred to in nearly every section.
In reading the proposed rule, it becomes evident that the Centers for Medicare & Medicaid Services (CMS) is clearly working toward aligning all Medicare Part B payment systems with the Quality Payment Program and its two tracks: MIPS and Advanced Alternate Payment Models (APM).
To learn more about the Quality Payment Program, see AAPC blog article, “2018 QPP Proposed Rule Excludes More Clinicians from MIPS.”

MIPS and Appropriate Use Criteria (AUC)

CMS states in the 2018 MPFS proposed rule that they “have proposed in the CY 2018 Quality Payment Program proposed rule to develop a direct tie between MIPS and the AUC program.” In that rule, CMS proposes to give MIPS credit to ordering professionals for consulting AUC using qualified clinical decision support mechanisms (CDSM) as a high-weight improvement activity for the second MIPS performance period, beginning Jan. 1, 2018.
CMS is also considering how the AUC program could serve to support a quality measure under the MIPS Quality performance category.
To learn more about the AUC program, see AAPC blog article, “CMS to Implement Advanced Diagnostic Imaging Monitoring Program.”

Value-based Payment Programs Converge with MIPS

CMS also discusses in the 2018 MPFS proposed rule plans for aligning Medicare Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS) reporting criteria with MIPS. Both programs end on Dec. 31, 2018.

Proposed Changes to PQRS Reporting Criteria

CMS is proposing to lower the criteria they would apply to the data used to determine whether an eligible professional (EP) or group practice has satisfactorily reported to avoid the 2018 PQRS payment adjustment, which has already been submitted for the 2016 reporting period, from nine measures across three National Quality Strategy (NQS) domains, where applicable, to six measures with no domain or cross-cutting measure requirement (similar to MIPS). This would apply to EPs submitting data via claims, a qualified registry (except for measures groups), a qualified clinical data registry (QCDR), or a direct EHR product and EHR data submissions vendor product.
See Table 20 in the 2018 MPFS proposed rule for a summary of the proposed modifications to the previously finalized satisfactory reporting criteria for individual clinicians to avoid the 2018 PQRS payment adjustment.

Proposed Changes to Medicare EHR Incentive Program Reporting Criteria

CMS is also proposing to change the reporting criteria for EPs and groups who chose to electronically report clinical quality measures (CQM) through the PQRS Portal for purposes of the Medicare EHR Incentive Program. The reporting criteria would align with the revised PQRS reporting criteria.
An EP or group who satisfies the proposed reporting criteria may qualify for the 2016 incentive payment and may avoid the downward payment adjustment in 2017 and/or 2018.

Proposed Changes to Value Modifier Reporting

The maximum downward/upward payment adjustments for PQRS and the VM combine is plus or minus 6 percent. To align with MIPS, which has a maximum downward/upward adjustment of plus or minus 4 percent, CMS is proposing to:

  • Hold harmless all groups and solo practitioners in Category 1 from downward payment adjustments under quality-tiering for the last year of the program (2018).
  • Reduce the maximum VM upward/downward adjustment under the quality-tiering methodology in 2018 from four times an adjustment factor to two times an adjustment factor for those classified as high quality/low cost and from two times an adjustment factor to one times an adjustment factor for those classified as either average quality/low cost or high quality/average cost.

Implementing MACRA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to develop care episode and patient groups, and classification codes for such groups. To that end, CMS posted a list of patient relationship categories May 17 on its website.
In addition to the National Provider Identifier (NPI) of the ordering clinician, claims submitted for items and services on or after Jan. 1, 2018 must include applicable codes established for:

  • Care episode groups,
  • Patient condition groups, and
  • Patient relationship categories.

Patient relationships would be identified on claims with the following proposed HCPCS Level II modifiers (as shown in Table 26):
X1 Continuous/broad services
X2 Continuous/focused services
X3 Episodic/focused services
X4 Episodic/focuses services
X5 Only as ordered by another clinician


CMS is also proposing changes to the Medicare Shared Savings Program (MSSP) with the intention of facilitating the success rate of Accountable Care Organizations participating in the MSSP under the Quality Payment Program.
See the 2018 MPFS proposed rule for commenting instructions.

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Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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