MIPS vs. PQRS: Reporting requirements for the MIPS Quality Performance Category

This post was updated based on the Quality Payment Program final rule on October 24, 2016.

The Centers for Medicare and Medicaid Services (CMS) recently released the much-anticipated final rule that offers details on how CMS will implement many of the key quality- and payment-related provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
With the start of the program around the corner on January 1, 2017, it is important for healthcare providers and provider organizations to start the process of analyzing the requirements they face under MACRA now.

Overhauling existing reporting programs

The Merit-Based Incentive Payment System (MIPS) is part of the new Quality Payment Program under MACRA and combines requirements previously included in three separate programs administered by CMS: the Physician Quality Reporting System (PQRS), the Medicare EHR Incentive Program, and the Value-Based Payment Modifier. MIPS implementation includes calculating a Composite Performance Score for all participating clinicians that represents performance in four categories, each with their own requirements and weighted values (applicable to the 2017 performance year).

PQRS, Meaningful Use, and Value-Based Payment Modifier become the Merit-Based Incentive Payment System (MIPS)

CMS has estimated that between 592,000 and 642,000 eligible clinicians will be required to participate in MIPS in 2017. With the first performance period set to begin on January 1, 2017, there is no time like the present to begin learning about the requirements and preparing for success.

Rolling PQRS requirements into the MIPS Quality Performance category

Medicare providers who have previously participated in the Physician Quality Reporting System (PQRS) will see some similarities in the MIPS Quality Performance category, worth 60% of the MIPS Composite Performance Score in 2017. In response to one of the biggest criticisms from providers about the PQRS program, CMS is proposing to allow individual MIPS eligible clinicians and groups the flexibility to determine the most meaningful measures and reporting mechanisms for their practice when reporting for the Quality Performance category.

A summary of the key requirements and characteristics of the MIPS Quality Performance category are below:

  • Report 6 measures from a pool of ~200 quality measures, including 1 outcome measure, or another high priority measure (appropriate use, patient safety, efficiency, care coordination, or patient experience) if an outcome measure is unavailable.
    • The existing PQRS requirement that patient-facing clinicians must report one cross-cutting measure does not exist in the MIPS program in 2017.
    • The PQRS requirement that reported quality measures must span a set of National Quality Strategy (NQS) domains also does not exist in the MIPS program
  • Measures can be reported by individual MIPS eligible clinicians via claims, qualified clinical data registry (QCDR), qualified registry, or EHR (or providers can report via administrative claims, which requires no data submission).
  • Measures can be reported by groups via QCDR, qualified registry, EHR, CMS web interface (for groups 25+), CMS-approved survey vendor for CAHPS for MIPS, or administrative claims.
  • If reporting via QCDR, qualified registry, or EHR, data must be submitted for at least 50% of the MIPS eligible clinician’s or group’s patient population across all payers.
    • There is no longer an option to report Measures Groups under MIPS.
  • If reporting via Medicare Part B claims, data must be submitted for at least 50% of the Medicare Part B patients seen during the performance period to which the measure applies.
  • Individual MIPS eligible clinicians and groups can elect to report individual measures or a specialty measure set, which may include fewer than six measures. If the specialty set includes more than six measures, eligible clinicians and groups can choose to report on any six that include 1 outcome measure, or another high priority measure (appropriate use, patient safety, efficiency, care coordination, or patient experience) if an outcome measure is unavailable.
  • One population measure, all-cause hospital readmissions, will be automatically calculated by CMS using submitted Medicare claims.
  • During the 2017 transition year, eligible clinicians can achieve full participation in the MIPS Quality performance category by reporting on a minimum of one continuous 90-day period for the majority of the submission mechanisms. This 90-day period can occur anytime within 2017, as long as the period begins on or after January 1, 2017, and ends on or before December 31, 2017.

CMS has heeded the call to streamline its various quality and payment programs and ease certain requirements—for example, by reducing the number of reported quality measures from 9 under PQRS to 6 under MIPS and by eliminating the cross-cutting measure requirement in 2017.

Even so, given the short timeline for preparation and many commercial plans implementing similar programs, it’s more important than ever to prepare your organization to manage the requirements. Stay up to date on future posts analyzing the requirements of MIPS and MACRA by signing up for our newsletter.


Further reading:
6 ways to improve MIPS quality performance with the data you already have
MIPS exceptional performance bonus: how much could you earn?

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