Optimize MIPS Scoring for Your Practice

Optimize MIPS Scoring for Your Practice

Learn how MIPS scoring works in 2017, and make it a money-saving game with better patient outcomes.

To fulfill requirements of the federally-regulated Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP), you need to know what data to report; how to report; how long to report; and on which providers to report. Then, you must figure out how your practice scored so you can anticipate a negative or positive payment adjustment.

The Centers for Medicare & Medicaid Services (CMS) provides Quality and Resource Use Reports (QRUR) for clinicians to see their past performance scores; however, by the time these reports are published, you are usually 75 percent done with the performance year. Real-time outcome measures are your best bet to know how your clinician or clinician group will score in the current reporting year.

What is Macra

Unless you are participating in an Alternative Payment Model (APM) (as of this publication less than 2 percent of all eligible providers can or will be in an APM), MIPS is your only participation option because The Medicare Access and CHIP Reauthorization Act (MACRA) replaced the Certified Electronic Health Record Technology (CEHRT), the Physicians Quality Reporting System (PQRS) and the Value-based Modifier (VM) quality initiatives with MIPS.

MIPS scoring is unique in the 2017 transition year. Here’s how to do it.

Tally Your Score

There are three elements to scoring in 2017 as part of QPP:

  • Quality;
  • Advancing Care Information (ACI); and
  • Improvement Activities (IA).

Cost is a fourth scoring element, but is not scored in 2017, so it’s worth zero points this year. Here is the default breakdown of scoring out of 100 possible points:

1. Quality, 60 percent or 60 points

2. ACI, 25 percent or 25 points

3. IA, 15 percent or 15 points

Getting a perfect score will not be easy; understanding there is a minimum threshold is easy and paramount.

In 2017, avoiding a negative payment adjustment is as easy as reporting one measure for one patient, which earns the clinician or clinician group 3 points. To be eligible for a potential regular bonus, 4-69 points must be earned. Score 70 points or higher merits an “extraordinary” bonus. The exact amount of the extraordinary bonus has not been determined yet because it is a pool shared by the total of those successfully reaching the 70-point mark. How many bonus dollars are extraordinary versus standard also has not been determined. Since the program exists in a budget-neutral environment (i.e., unable to spend more than taken in), if many succeed, the result is less bonus for everyone.

Quality Measures and Scoring Optimization

Quality measures are like Physician Quality Reporting System (PQRS) measures. Full reporting in 2017 requires six quality measures, which could garner 60 points (if all are high priority measures worth 10 points each). That means only 10 points to go for an extraordinary bonus, right? Not so fast: Points are given for “successful” reporting, which means you must meet or exceed measure requirements on greater than 50 percent of all eligible patients in the reporting year.

It is possible (and a good idea) to identify patients who will help clinicians do well on selected measures. Some registries provide optimization software to help identify ideal patient populations by analyzing a clinician or clinician group’s data.

Another way to optimize scoring is to identify two or more clinicians in a practice whose work represents 51 percent of the group’s patients and report data for only those clinicians. Even in a larger group practice, reporting on all eligible clinicians is neither required nor wise if a limited number of them can be used to access greater than half the group’s patients and create elevated scoring opportunity. Keep in mind: If the performance of those who report is good, the entire practice wins — if they fail, everyone fails.

Certain reporting options can also improve your odds for successful reporting. A quality clinical data registry (QCDR), for example, affords access to measures not available via a claims registry. Typically, they are subspecialty-focused, create an invested “steward,” and are unique measures not available in the pool of general MIPS quality measures. The measure steward is the sponsoring organization required to co-create proprietary QCDR measures. QCDR measures often represent work for subspecialists that the larger body of quality measures did not well address. If measures are new and/or not vetted in (or prior to) a reporting year, maximum scoring per measure is 3 points, even if a clinician or clinician group meets or exceeds measure requirements. Only if the QCDR measures are vetted (i.e., not in their first year of use, or there is objective benchmark performance against which performance is measured) may they be worth 10 points.

Clinicians must select measures that include either one outcome measure or one high priority measure. Failing to do this will cause you to lose points from the magic number of 70. Know which measures work; whether measures are outcome or high priority; and which clinicians’ performance could optimize data. Work smarter, not harder, to identify and report quality measures.

ACI Scoring Optimization and Hardship Exemptions

ACI requires meaningful use of certified electronic health record technology (CEHRT), and is worth 25 percent of the total MIPS quality score. If hardship exceptions exist, however, the ACI category counts for zero points and the 25 percent is reallocated to the quality performance category, making the quality category worth 85 potential points.

Hardship exceptions are:

1. Insufficient internet connectivity. The entire organization must have insufficient internet for this exception to be accepted. If a practice has multiple locations or affiliates and even just one site has sufficient internet connectivity, CMS expects the practice to use the better-connected site to report data.

2. Extreme and uncontrollable circumstances. These are typically fiscal and natural disaster-related. Bankruptcy or debt restructuring and practice or hospital closure are typical fiscal impediments to this exemption applies. Earthquake, fire, hurricane, or other weather-related issues could exempt a practice, as well. If downtime is limited and uptime expansive, get rolling with reporting as soon as possible. If the CEHRT was not damaged or destroyed (remember, cloud-based systems should be safe) then this exemption does not apply.

3. Lack of control over CEHRT. If your EHR was decertified, submit the certification number of the product on the exception application.

Remember: Any provider/practice may apply for the hardship exception. Applications opened Aug. 2, 2017.

In addition to the above exceptions, the following MIPS eligible clinicians are automatically opted out and do not need to submit a quality Payment Program Hardship Exception Application:

1. Hospital-based MIPS clinicians

2. Physician assistants

3. Nurse practitioners

4. Clinical nurse specialists

5. Certified registered nurse anesthetists

6. Non-patient-facing clinicians (e.g., pathologists)

Although the ACI category affords access to 155 possible points, the maximum points you can earn is 100 points. A base score of 50 points is needed. If not met, the clinician or clinician group gets a zero for the ACI category. Achieving, roughly two-thirds of the total (to obtain 100 points) is quite possible. Another great aspect of the ACI measure group is most of the measure questions are simply “yes” or “no” — the measure was either done or not done. Since ACI measures are specific to the EHR used, it’s pretty simple to know whether a desired measure is available and utilized.

The ACI measure set has two options, which correlate directly with edition of CEHRT you are using:

1. ACI Objectives and Measures. These are used if a practice has technology certified to the 2015 edition or if it’s a combination of 2014 and 2015 editions that support the five measures (below). This group also requires “summary of care” information to be sent, received, and accepted for eligible patients.

2. 2017 ACI Information Transition Objectives and Measures. These may be used if the technology is certified to the 2014 edition, the 2015 edition, or a combination of the two. This option requires health information exchange participation. There are four measures available.

Both of these measures have performances rates worth up to 10 percent for each measure, depending on how well they were achieved and scored.

ACI Base Score Measures

Both the transition and non-transition ACI objectives and measures have a base score consisting of three areas:

1. Security risk analysis

2. E-prescribing

3. Provider-patient access

Once analyzed, the base score is added to the performance score, worth potentially 40 (i.e., max for ACI non-transition) and 50 (i.e., max for ACI 2017 transition) points. The bonus points then are added to see what the total score achieved could be. Appendix A is the best CMS resource to detail the point allocation for each measure and ACI objectives and performance measure set options. Once a final ACI score is determined, 25 percent of that is the total ACI score (e.g., 88 points x 25 percent = 22 points or 22 out of a possible 25 points).

IA and Scoring Optimization

IA has nine subcategories with measures weighted as medium- or high-value measures. Medium-value measures are worth 10 points, and high-value measures, 20 points. The nine subcategories are:

1. Expanded Practice Access

2. Population Management

3. Care Coordination

4. Beneficiary Engagement

5. Patient Safety and Practice Assessment

6. Participation in an APM

7. Achieving Health Equity

8. Integrating Behavioral and Mental Health

9. Emergency Preparedness and Response

If a practice is a federally designated rural area or has 15 or less providers, then they must report on one high-priority measure or two medium-priority measures. If the practice has greater than 15 providers, then it must report one of the following options:

1. Two high-priority measures

2. One high-priority measure and two medium-priority measures

3. Four medium-priority measures

A practice can get full credit for the IA performance category without doing the above work if they are a certified patient-centered medical home (PCMH), including medical homes model or comparable specialty practice. If under the same tax identification number (TIN) only one group is certified as a PCMH, all national provider identifiers (NPIs) linked to the entire group are eligible for full IA credit.

If an eligible clinician participates in an Alternative Payment Model (APM) and the TIN/NPI appears on the APM participant list at any time during the performance period, the practice is credited one-half the total points for the IA performance category. Finally, if participating in an MIPS APM, and the clinician is included in one of the three assessment dates (March 31, June 30, or Aug. 31), they are scored under the APM Scoring Standard.

Remember: The goal is 70 or higher, so exemption from IA due to actual or TIN collective participation as a PCMH or the tax ID linked to an APM affords nominal points. These IA points, when coupled with the quality measures and even nominal ACI points, should easily elevate scoring above 70 points.

Stay Focused on the Prize

The MIPS scoring system is meant to reduce costs and optimize patient outcomes. Keep the target in mind. Becuase the quality score is added to the ACI and IA scores, estimate how well in each section your clinician(s) will perform to see how many total points you may achieve. The ongoing goal is efficient management of this system while preparing for 2018; pragmatic lessons from 2017 can guide you into the 2018 reporting year. The more clinicians are aware of what is measured and how, the better everyone will do in the QPP.


2017 MIPS Quality Performance Category Fact Sheet:

QCDR: https://qpp.cms.gov/docs/QPP_2017_CMS_Approved_QCDRs.pdf

CMS, Quality Payment Program: https://Qpp.cms.gov

MIPS Overview, Quality Payment Program: https://qpp.cms.gov/mips/overview

IA Fact Sheet: https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf

ACI Performance Category Fact Sheet (pages 7-8):

Quality Fact Sheet:

Hardship Exemption Link:

One of the original 16 CMS Qualified Registries, Patient360: www.Patient360.com

Patient360 QCDR: http://patient360.com/qcdr-full-submission

Douglas J. Jorgensen

Dr. Jorgensen is the owner and Board Chair of Patient360, practicing pain management and osteopathic manipulation in central Maine. He is triple boarded in Family Practice and OMT, as well as Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine, and has a CAQ in Pain Medicine. As a consultant and speaker, he lectures nationally on billing and coding issues. He has published a 2nd edition of A Physician’s Guide to Billing and Coding with his brother, Raymond T. Jorgensen, also a certified professional coder and national expert on practice management, billing and coding issues.

Latest posts by Douglas J. Jorgensen (see all)

About Has 3 Posts

Dr. Jorgensen is the owner and Board Chair of Patient360, practicing pain management and osteopathic manipulation in central Maine. He is triple boarded in Family Practice and OMT, as well as Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine, and has a CAQ in Pain Medicine. As a consultant and speaker, he lectures nationally on billing and coding issues. He has published a 2nd edition of A Physician’s Guide to Billing and Coding with his brother, Raymond T. Jorgensen, also a certified professional coder and national expert on practice management, billing and coding issues.

Leave a Reply

Your email address will not be published. Required fields are marked *