MACRA Quality Payment Program Guide. Sample page. Simplifying Medicare MIPS & APM reporting for practitioners. Power up your coding optum360coding.

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1 2019 MACRA Quality Payment Program Guide Simplifying Medicare MIPS & APM reporting for practitioners Power up your coding optum360coding.com

2 Contents Chapter 1. MACRA and the Quality Payment Program... 1 Passage of the Medicare Access and CHIP Reauthorization Act of Replacement of the Sustainable Growth Rate... 3 Figure 1.1. Cuts to s Under SGR Methodology... 3 Quality Payment Program Established... 4 Figure 1.2. Clinician Pathways of Participation... 7 Figure 1.3. QPP Transition Year Timeline... 8 Chapter 2. MIPS and Advanced APMs... 9 Background... 9 Figure 2.1. The Quality Payment Program... 9 Table 2.1. Requirements for Participation by Category...11 Quality...11 Activities Table 2.2. Activity Participant Requirements...12 Advancing Information...14 Figure 2.2. Calculation of a Clinician s ACI Score...14 Cost...17 Individual and Group Participation...18 Eligibility Requirements...20 Provider Types...20 Voluntary Participation...21 Figure 2.3. Clinicians Scoring Pathway Timeline...24 Clinicians Can Pick Their Pathway...25 Figure 2.4. Clinician Pathways for Participation During the Transition Year...25 Test Pace Option...25 Partial/Full Options...25 Figure 2.5. QPP Timeline...26 Alternative Payment Models...26 MIPS Alternative Payment Models (APMs)...28 Qualifying APM Participant...28 Getting Started in the Quality Payment Program Chapter 3. Reporting and Submitting Data Under MIPS and APMs Data Submission Methods for MIPS Data...37 Table 3.1. Data Submission for MIPS Categories...37 Table 3.2. Third-Party Intermediary Status for Approval and/or Costs...38 Description of Data Submission Methods...38 Table 3.3. Submission Method Descriptions...38 Reporting Quality Measures...51 CPT 2017 American Medical Association. All Rights Reserved. i

3 Chapter 2. MIPS and Advanced APMs Background The MACRA final rule established the Quality Payment Program (QPP) effective January 1, Within the QPP there are two interrelated pathways: Advanced Alternative Payment Models (APM) and the Merit-based Incentive Payment System (MIPS). Eligible clinicians (EC) must select which track MIPS or Advanced APMs they will participate in based on the practice size, specialty, location, and patient population. Unlike previous quality initiatives, a provider does not have to enroll in the QPP. However, groups wishing to participate in the MIPS program via the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey measures or CMS Web Interface (WI) do have a June 30 deadline each year. The CAHPS for MIPS survey is an optional quality measure that groups participating in MIPS can elect to administer. In the quality performance category, it would count as a patient experience measure. In addition, MIPS eligible clinicians may also be awarded points under the improvement activities performance category for administering the survey. Figure 2.1. The Quality Payment Program The Merit-based Incentive Payment System (MIPS) OR Advanced Alternative Payment Models (Advanced APMs) The focus of this chapter is to provide an overview of the Merit-based Incentive Payment System and the Advanced Alternative Payment models. Information on reporting requirements and scoring is provided in subsequent chapters. Merit-based Incentive Payment System MIPS is the track for clinicians who opt to participate in traditional Medicare as opposed to participating through an Advanced APM. In doing so, clinicians may earn a payment adjustment related to evidence-based and practice-specific quality data. As a result, depending on the degree and success of performance in all four categories for CY 2017, clinicians will receive one of the following: Positive payment adjustment in which additional compensation is received Neutral payment adjustment that neither increases nor reduces Medicare payments Negative payment adjustment of up to 4 percent of Medicare payment furnished in CY 2019 MIPS incorporates pieces of three former Medicare reporting programs: Quality Reporting System (PQRS) Medicare EHR Incentive Program/Meaningful Use Value-based Payment Modifier J Important Information For more information regarding registering a group for the CAHPS for MIPS survey, please visit: roup-registration. Quick Tip MIPS is not applicable to hospitals or facilities. CPT 2017 American Medical Association. All Rights Reserved. 9

4 MACRA Quality Payment Program Guide Chapter 2. MIPS and Advanced APMs Data Submission Methods Administrative Claims Selected quality measures are reported through routine billing processes and no additional data submission method is required. Qualified Registry Qualified Clinical Data Registry (QCDR) CMS Web Interface Consumer Assessment of Healthcare Providers and Systems (CAHPS) When using qualified registries or QCDRs as the data submission method, the ECs within the group must select one from the CMS-approved list to ensure the entity selected has met CMS submission standards and criteria. For more information, visit: and Clinicians who participate at the group level will have their performance assessed and scored across the tax identification number (TIN) reported to include items and services provided by individual clinicians NPIs associated with that TIN but who are not required to participate in MIPS. To register for the CMS Web Interface and CAHPS for MIPS Survey, visit: and CMS-approved entity that collects clinical data from an EC or group practice for submission to CMS on the behalf of the EC or group. CMS-approved entity that collects clinical data for patient and disease tracking purposes as a means of fostering quality of care improvements for patients. Each QCDR provides specific data submission instructions to MIPS clinicians. Secure, internet-based portal for groups of 25 or more ECs to submit quality data directly to CMS; the Web Interface is prepopulated with claims data from Medicare Part A/B beneficiaries who have been assigned to that group. The group is required to complete remaining data fields for those patients. CMS-approved survey vendor that collects and submits data regarding the patient care experience at the practice to CMS on behalf of the group. CPT 2017 American Medical Association. All Rights Reserved. 19

5 Appendix A. All Quality Measures ID NAME DESCRIPTION TYPE NQS DOMAIN DATA SPECIALTY SUBMISSION MEASURE SET PRIMARY STEWARD 1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)* Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period 5 Heart Failure (HF): Angiotensin- Converting Enzyme (ACE) Inhibitor or diagnosis of heart failure (HF) with a current or prior left Angiotensin Receptor ventricular ejection fraction Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge 6 Coronary Artery Disease (CAD): Antiplatelet Therapy diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel 7 Coronary Artery Disease (CAD): Beta- Blocker Therapy-Prior diagnosis of coronary artery Myocardial Infarction disease seen within a 12 month (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) period who also have a prior MI or a current or prior LVEF <40% who were prescribed betablocker therapy 8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge 9 Anti-Depressant Medication Management * High priority measure Percentage of patients 18 years Process of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) Intermediate Effective Clinical Claims, CMS Outcome Web Interface, EHR, Registry Internal, Preventive, General Practice/ Family Effective Clinical EHR, Registry Internal, Cardiology, Hospitalists, General Effective Clinical National Committee for Quality Assurance Registry Cardiology American Heart Association Effective Clinical EHR, Registry Cardiology, General Effective Clinical EHR, Registry Cardiology, Hospitalists, General Effective Clinical EHR Internal, Mental/Behavioral Health, General National Committee for Quality Assurance CPT 2017 American Medical Association. All Rights Reserved. 83