• 2017 MIPS - How to Avoid the Penalty

    On January 1, 2017 the new Medicare Quality Payment Program (QPP) began. This is a new Medicare payment system created by the Centers for Medicare & Medicaid Services (CMS) to replace Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM) programs. There are two pathways, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models. Most physicians in 2017 will be part of the MIPS pathway.

    NOTE: The MIPS program is specific to Medicare Part B only, and is not affected by Medicare Advantage patients.


    January 1, 2017 through December 31, 2017 is the first official participation year for the MIPS pathway and is considered a "transition year" by CMS. CMS is offering 3 different participation routes for CY 2017 as they are as follows:

    1. Submit Something: This option is to submit a minimal amount of data and avoid the -4% penalty in 2019. This amount of data can simply be submitting one quality measure for one patient, or one clinical practice improvement activity. By choosing this option you avoid the penalty but DO NOT qualify for an incentive payment or bonus. 
    2. Submit a Partial Year: This option is to submit data for a continuous 90 days in 2017. By choosing this option physicians will avoid the -4% penalty in 2019 as well as have an opportunity to earn an incentive payment. 
    3. Submit a Full Year: This option is to submit a full years data for all of the 2017 MIPS categories (Quality, Advancing Care Information, and Clinical Practice Improvement Activities). By choosing this option physicians will avoid the -4% penalty in 2019 as well, have an opportunity to earn an incentive payment and bonus in 2019. 

    Do nothing: If no data is submitted in 2017 an automatic -4% penalty will be assessed in 2019 on all Medicare Part B payments.

    NOTE: If you are participating in an IPA, ACO, etc. contact administration to assure they will be helping you with 2017 Medicare reporting.

    MIPS Pathways

    HCMS encourages all physicians to participate in the 'Submit Something' option, especially physicians who have either chosen to not participate or have been unsuccessful in past year with PQRS and MU. 

    Below are a few methods and instructions on how to Submit Something in 2017:


    Clinical Practice Improvement Activities (CPIA) is a new performance category within MIPS where physicians are rewarded for activities focused on care coordination, beneficiary engagement and patient safety. 

    STEP 1: Review the available improvement activities here
    STEP 2: Choose one improvement activity. A physician and his/her practice should choose an activity that they are already doing or can easily be implemented in 2017. 
    *It is important to note that "Adding" an activity on the website linked above does not indicate participation, this is for personal use only, a separate submission mechanism is required as seen in Step 4. 
    STEP 3: Once an activity is selected by sure that 2017 documentation of the activity is kept on record in case of an audit. For most activities, physicians will be attesting that the activity was conducted for at least 90 days.  STEP 4: Attest to participation in the chosen improvement activity. Deadline to do this for 2017 MIPS performance period is March 31, 2018. Below are the submission options for the CPIA category in 2017. 
    1. Attestation - Attestation portal has not been provided by CMS, link will be provided when available. 
    2. Qualified Clinical Data Registry (QCDR) - list for approved MIPS QCDRs has not been published by CMS, will provide when available. 
    3. Qualified Registry - list for approved MIPS qualified registries has not been published by CMS, will provide when available.
    4. EHR - speak with your EHR vendor regarding MIPS capabilities in 2017. 


    The Quality category within MIPS is very similar to PQRS as is submitting measures through claims. MIPS quality measures have new specification codes. The claims submission mechanism is only available for individual physician reporting and cannot be done for group reporting. Please review the instructions and links below. 


    STEP 1: Review the MIPS quality measures here. Scroll down to the "Filter by" options and filter measures by "Data Submission Method", select the claims box in the drop down menu, This will show all measures that are able to be submitted through claims. See highlighted areas on the screen example below. Physicians are also able to filter measures by specialty under the "Specialty Measure Set" drop-down menu to help narrow down the list of measures. 

     Quality-Claims - Screenshot1


    STEP 2: Choose one quality measure that suits the physicians practice/specialty and review the measure details by clicking the arrow next to each measure to expand. Be sure to note the "Quality ID" under "Measure Number" for the measure chosen, this number will be needed for future steps. See highlighted areas on the screen example below. 

    *Chosen measures can be added to "Selected Measures" and a CSV Excel File can be downloaded for personal record, doing this is NOT a submission of measures or an attestation, this is for organizational and personal use only.

     Quality-Claims - Screenshot2


    STEP 3: Download the Claims-Registry-Measures zip-file. To ensure you have the most up-to-date file, download directly from herescroll down to "Documents & Downloads", click on "Quality Measure Specifications" under "For Registries, Qualified Clinical Data Registries (QCDRS) & EHR Vendors". See the highlighted areas on the screen example below. 

     Quality-Claims - Screenshot3


    STEP 4: Once the zip-file has downloaded, open the file. You will then see two additional zip-files, click into file titled the "Claims-Registry-Measures" (NOT Web-Interface-Measures). This will take you to another file titled "Claims-Registry_Measures", click into this file. You should now see a long list of numbered PDF files. See instructional images below. 

     Quality-Claims - Screenshot4


    STEP 5: Refer to the "Quality ID" number found in Step 2 for your selected measure. Find the corresponding measure number in the "Claims-Registry-Measures" file just opened within the list of PDFs. For example, if your Quality ID is 093, find the PDF titled 2017_Measure_093_Claims. 

    *Some measures have duplicate files, one for claims and one for registry, be sure to open the the PDF with "Claims" in the title NOT "Registry". See below for an example. 

     Quality-Claims - Screenshot5


    STEP 6: Once the PDF is open review the Instructions. 
    STEP 7: Identify the acceptable patient age restrictions, diagnoses codes, and CPT or HCPCS codes under Denominator Criteria. A combination of the diagnoses codes and CPT/HCPCS codes is what is required on the billed CMS 1500 claim form or 837 e-claim to be eligible for submission of the chosen measure. See example below. 

    Quality-Claims - Screenshot6


    STEP 8: Review the Numerator requirements (found after the Denominator criteria). The numerator codes found in this section are what will be added to the CMS 1500 claim form with the corresponding denominator criteria found in Step 7. Review each of the "Numerator Quality-Data Coding Options" and choose the appropriate scenario and associated code. See example below.
    These numerator codes will be added in after the CPT/HCPCS codes under "Procedures, Services or Supplies" on the CMS 1500 form (each will have their own line). A 0.01 charge amount under "$ Charges" on the CMS 1500 form for each numerator code must be entered for proper submission.  The rest of the CMS 1500 form will be entered in as usual and billed normally. 

    Quality-Claims - Screenshot7


    STEP 9: Submit the CMS 1500 claim form with both the denominator and numerator codes and criteria. 

    IMPORTANT: Although only one measure for one patient is required to avoid the MIPS -4% penalty in 2019, HCMS STRONGLY RECOMMENDS submitting at least 5 claims for the chosen measure(s) if possible, to ensure proper submission. If a claim is denied due to an unrelated error the measure will not be counted or viewed by CMS and a penalty will be assessed in 2019.