MIPS FAQs

The following are frequently asked questions for the Merit-based Payment System track of the CMS Quality Payment Program.

(Updated 7/7/2018).

Section I. General Questions

1. Question:  How did the Bipartisan Budget Act of 2018 impact MIPS?
   • Answer: The Bipartisan Budget Act of 2018 went into law in February 2018 and changed MIPS and future years into three significant ways. (Reference: Bipartisan Budget Act of 2018)
     • CMS will not be required to use the mean or median performance of all clinicians in the MIPS to determine the performance threshold starting in the 2019 performance year.  For the first two years of the MIPS CMS was allowed to determine this level, choosing 3 points in 2017 and 15 points in 2018.  CMS has been instructed by Congress to gradually increase the performance threshold over the next three years. Starting in 2022 the performance threshold will be determined by the mean or median performance of all clinicians in the MIPS.
     • CMS will not be required to increase the weighting of the Cost category of MIPS to 30% in 2019 and future years.  The cost category weighting for the 2018 performance year is 10%. It is anticipated that CMS will gradually increase this percentage over the next three years.
     • Part B medication payments will no longer be used to determine payment thresholds for eligibility in the MIPS or used to determine payment adjustments.

Section II.  Quality Category

• Question: For MIPS Quality Measure ID#001 “Diabetes: Hemoglobin A1c Poor Control” can any HbA1c value obtained during the performance year be used when submitting this measure?
  • Answer: “The eligible clinician or group should report the last Hemoglobin A1c obtained, and if the level is > 9%, the Performance Met option for numerator applies.” (Source: CMS Quality Payment Programs Support Team, May 25, 2018)
• Question: For MIPS Quality Measure ID#001 “Diabetes: Hemoglobin A1c Poor Control” if two clinicians not in the same group obtain HbA1c results on the same patient, should the most recent value obtained by the individual clinician or the most recent value obtained by either clinician be reported?
  • Answer: “…If reporting as a group, the most recent HbA1c level acquired by either clinician should be the one utilized for determination of the numerator for the patient. If reporting as individuals, it is the last HbA1c level obtained by the eligible clinician who is individually reporting that should be utilized.”  (Source: CMS Quality Payment Programs Support Team, May 25, 2018).
  • Comment: Based on this response clinicians not in the same group should use the most recent HbA1c level obtain by their practice when determining how to submit this measure.
• Question: Are clinicians required to use quality measures identified by CMS as suitable for their specialty, or can any measure be used?
  • Answer: Clinicians should report quality measures that are applicable for their specialty.  There is no specific requirement that they limit their selection to measures identified by CMS as those frequently used by their specialty.  (Source: CMS Quality Payment Program 2018 Final Rule).
• Question: A significant number of MIPS quality measure specification documents state that the measure needs to be submitted a minimum of once per the reporting period.  An example of this is MIPS Quality Measure ID# 006 “Coronary Artery Disease (CAD): Antiplatelet Therapy.”  What happens if there are multiple eligible encounters during the performance period?  Are practices required to submit data for the measure based on any one of the encounters, do they need to submit data for each encounter, or should they just report data for the most recent encounter?
  • Answer: “As the instructions state the measure is to be submitted a minimum of once performance period on denominator-eligible patients, you are only required to submit the appropriate QDC for one eligible encounter. However, if you submit QDCs for multiple denominator-eligible encounters for a specific patient, the most advantageous quality-data code will be used to determine performance and scoring.” (Source: CMS help desk June 1, 2018)
• Question: When reporting Quality Measure ID# 110 (Influenza Vaccinations) via a registry and the patient is seen during both the (January to March and October to December flu seasons, should the practice submit performance for both encounters or just one?
  • Answer: Both encounters are submitted even if they have different results.  For example, if the patient was seen in the Spring (January-March) of 2018 and there is no documentation that the patient received the vaccine the practice would report that the encounter as the “performance not met” using the appropriate codes.  If the patient had another visit in October-December and the influenza vaccine was administered, they would also report the encounter but as “performance met.”   This measure has two reporting periods and influenza vaccination status needs to be addressed for both reporting periods for the measure’s performance to be met.   Date: 6/7/2018 (Source: CMS Quality Support)
• Question:  For Quality Measure ID #282: “Dementia: Functional Status Assessment – National Quality Strategy Domain: Effective Clinical Care” if the patient refuses to take the test for any reason other than physical or mental impairments, how should this be reported?  There is no exception for noncompliance/refusal.
  • Answer:  Noncompliance (e.g., refusal to undergo functional status assessment for any reason) is treated as “Performance not met” even if the refusal is documented.  It is treated the same as if the functional status assessment was never offered to the patient. Date: 6/7/2018 (Source: CMS Quality Support)
• Question: For Quality Measure ID #317 “Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented” the specification states that the measure needs to be submitted at least once during the reporting period.  If the patient is seen more than once during the reporting period is the practice obligated to report performance for each encounter, or can they just submit data for one encounter?  Also, if the practice does submit data from multiple encounters for the same patient, how is this used to determine the clinician’s/group’s performance on this measure?
  • Answer: “For this measure, eligible clinicians are only required to be submitted once per performance period for patients that meet the denominator criteria. The most advantageous quality-data code will be used if the measure is submitted more than once.” Date: 6/7/2018 (Source: CMS Quality Support)
• Question: For Quality Measure Quality Measures ID #317 “Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) – National Quality Strategy Domain: Effective Clinical Care,” practices need to submit this measure a minimum of once during the reporting period and for all hospital discharges.  Are practices obligated to report all eligible encounters in the outpatient setting and for all discharges, or only for all discharges?  In addition, how is the information submitted used to determine performance on this measure?
  • Answer: “This measure is to be submitted at two different frequencies, depending on the clinical setting: For all heart failure patients a minimum of once per performance period when seen in the outpatient setting AND submitted at each hospital discharge (99238* and 99239*) during the performance period. For the outpatient setting, the most advantageous quality-data code will be used if the measure is submitted more than once. You are correct that the measure should be reported for each discharge during the performance period; however, in these scenario, analysis would not be limited to the most advantageous QDC as Criterion 2 is considered “visit”.”  Date: 6/7/2018 (Source: CMS Quality Support)

Section III.  Promoting Interoperability (formerly Advancing Clinical Information) Category

1. Question: What is the minimum number of patients a practice needs to report for the Promoting Interoperability base  measures other than the security risk assessment?
   • Answer: Eligible clinicians and groups should submit data that shows a value of at least one in the numerator.  In other words, the required action must be completed for at least one patient. (Source: CMS Quality Payment Program 2018 Final Rule).
2. Question: If all of the base measure requirements are not met what is the highest score that a practice can achieve in the Promoting Interoperability category of MIPS?
   • Answer: All base measures must be satisfactorily reported in order for the practice to receive a score greater than zero for the entire Promoting Interoperability category. This is regardless of how will the practice scores on the performance measures of this category. (Source: CMS Quality Payment Program 2018 Final Rule).
3. Question: Regarding the “Patient-Generated Health Data” Promoting Interoperability category measure for 2015 ed CEHRT. If the provider incorporates an electronic document provided by the patient into the certified EHR, does this meet the measure’s performance requirement, or does actual data needed to be uploaded/transferred into the EHR.  For example, a patient uploads a PDF document of a consultative visit with their cardiologist into the their patient portal and the MIPS clinician, a primary care provider, then adds this document to a folder in their EHR. Would this meet the performance requirement for the measure?
   • Answer: The 2018 Patient-Generated Health Data promoting interoperability measure does not dictate the process that must be followed to incorporate data. The bullet below is included in the 2018 specification and confirms the eligible clinicians has flexibility in selecting the manner of incorporating patient generated health data that works best for their practice and needs. For the measure, we do not specify the manner in which providers are required to incorporate the data.
     • MIPS eligible clinicians may work with their EHR developers to establish the methods and processes that work best for their practice and needs. For example, if data provided can be easily incorporated in a structured format or into an existing field within the EHR (such as a C–CDA or care team member reported vital signs or patient reported family health history and demographic information) the MIPS eligible clinician may elect to do so. Alternately, a MIPS eligible clinician may maintain an isolation between the data and the patient record and instead include the data by other means such as attachments, links, and text references again as best meets their needs.
   • The measure requires that patient-generated health data from a non-clinical setting is incorporated into the certified electronic health record technology. MIPS eligible clinician or MIPS eligible clinician staff entering information from a clinical setting into an EMR does not count toward the measure as the measure requires patient generated data from a non-clinical setting. (Source: CMS Quality Support – Production: date: 7/5/18)
   • >>> Take away points:  PDF documents that contain healthcare related data that is generated outside of a clinical setting and loaded into the EHR meets the performance requirement for this measure.  Information that is uploaded by the patient into a patient portal or otherwise shared with the clinician that contains data/information that was generated in a clinical setting (e.g., lab values, radiology reports, consultative reports, images, etc.)  does not meet the performance requirement for this measures.   Examples of patient generated data that is generated outside of a clinical setting includes home glucometer readings, home blood pressure readings, personal fitness data, and other types of health care data generated outside of a clinical setting.
4. Question: A practice elects to report as a group but some members of the group are not using Certified EHR Technology.  How should the practice submit data in the Promoting Interoperability performance category of MIPS?
   • Answer: Only the data submitted by the clinicians using CEHRT will be used to determine the Performing Interoperability performance score, i.e., non-users are not factored into the final score.   For example, for a group of 100 clinicians, if 50 clinicians are not using CEHRT the Promoting Interoperability Score will be based on the performance of the 50 clinicians that are using CEHRT.  The non-users lack of  CEHRT in a group setting does not impact the groups final score in this category.
   • However, if a clinician reports as an individual and does not report Promoting Interoperability data, they are given a score of zero in this category.

Section IV.  Cost Category

1. Question: Will episode-based cost measures be used to determine cost scores in the 2018 performance year?
   • Answer: CMS has deferred the use of episode-based cost measures to determine the cost performance score until 2019, or potentially later years. In the 2018 performance year two measures will be used to determine cost performance (Source: CMS 2018 Cost Performance Category Fact Sheet)
     • Total Per Capita Cost measure
     • Medicare Spending Per Beneficiary measure
2. Question:  What does the Total Per Capita Cost measure actually measure?
   • Answer: The Total Per Capita Cost measure measures of all Medicare Part A and Part B costs during the MIPS performance period.  (Source: CMS 2018 Cost Performance Category Fact Sheet)
3. Question: what does the Medicare Spending Per Beneficiary measure actually measure?
   • Answer: The Medicare Spending Per Beneficiary measure looks at what Medicare pays for services performed by an individual clinician during a specific episode, including the three day period immediately before an admission and 30 days following admission. It includes all Medicare Part a and Part B claims during the episode.   The Medicare Spending Per Beneficiary is assigned to individual clinicians as identified by there unique TIN/NPI. (Source: CMS 2018 Cost Performance Category Fact Sheet)
4. Question: For the Total Per Capita Cost measure, how is the cost associated with a Medicare beneficiary assigned to an individual practice?
   • Answer: Medicare beneficiaries are only assigned to a Medicare Taxpayer Identification Number/National Provider Identifier (TIN/NPI) if they receive primary care services during the performance year. Beneficiaries for this measure are assigned to a single Medicare Taxpayer Identification Number/National Provider Identifier (TIN/NPI) via a two-step process:
     • In the first step CMS will evaluate the level of primary care services the patient received (as measured by Medicare allowed charges during the performance period) from primary care services from primary care providers, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) in that TIN-NPI than in any other TIN/NPI or CMS Certification Number (CNN) the patient will be assigned to TIN/NPI. (The CNN was formerly the Medicare Provider Number.)  If the patient received more primary care services from PCPs, NPs, PAs, of CNSs from a CCN than from another other NPI/TIN, the patient is assigned to the CCN and is excluded from risk adjustment.  If two NPI/TINs tie for the greatest share of the beneficiary primary care services the beneficiary is assigned to the TIN/NPI that most recently provided primary care services
     • The second step is used when the beneficiary did not receive primary care service from any PCP, NP, PA, or CNS during the performance period, but received more primary care services from non-primary care physicians within aTIN-NPI than in any other TIN-NPI or CCN, the beneficiary is assigned to a TIN-NPI in the second step. (Source: CMS 2018 Cost Performance Category Fact Sheet)
5. Question: For the Total Per Capita Cost measure, what services count as primary care services?
   • Answer: Evaluation and management services provided in the office and other non-inpatient and non–emergency-room settings, Initial Medicare (IPPE) visits and Annual Wellness Visits (AWV).  (Source: CMS 2018 Cost Performance Category Fact Sheet)
6. Question: Are there case minimums for the cost measures in 2018?
   • Answer: The case minimums for the two measures are as follows (Source: CMS 2018 Cost Performance Category Fact Sheet):
     • Total Per Capita Cost measure: 20 cases
     • Medicare Spending Per Beneficiary measure: 35 cases
7. Question: What happens if the case minimums are not met for one or both of the two cost measures in 2018? (Source: CMS 2018 Cost Performance Category Fact Sheet)
   • Answer: If both measures have adequate case minimums to be scored, the MIPS cost score will be the average of the two scores for these two measures.  If only one of the measures meets the minimum case requirement than it is used to determine the final Cost performance score.  If case minimums are not met for either measure CMS will reweight the cost category weighting to the Quality performance category. This will give the quality performance category a weighting of 60% in 2018.

Section V.  Improvement Activities

1. Question: When eligible clinicians report as a group do all clinicians in the group need to participate in the improvement activity?
   • Answer: Only one clinician in a group needs to actively participate in an improvement activity for a continuous 90-day period for the entire group to receive credit for the improvement activity. (Source: CMS Quality Payment Program 2018 Final Rule).
2. Question: Can improvement activities that were put in place prior to the performance year be used to meet the improvement activity requirement for the current reporting year?
   • Answer: Improvement activities there were put in place prior to the performance year can be used to meet the improvement activity requirement for one or more improvement activities. At least one clinician needs to be actively engaged with the improvement activity for a continuous 90-day period during the performance year to meet the requirement. (Source: CMS booth, HIMSS 2018 via direct communication)

Section VI.  MIPS Bonuses

Section VII.  MIPS APMs

1. Question: If a group of specialists are participating in a Medicare Shared Savings Program (MSSP) Track 1 Accountable Care Organization, does this impact how they submit MIPS performance data?
   • Clinicians that are on the Participation List for an MSSP Track 1 ACO on one of four “snapshot dates” in 2018(March 31, June 30th, August 31st or December 31st) will have significantly different reporting requirements than clinicians who are not engaged with a similar organization. They are in a “MIPS APM” and will receive the same MIPS score as each participant in the ACO. The ACO is obligated to report the quality measure performance based on the ACO quality measures. The practice automatically receives full credit for the improvement activities category of MIPS, which is 20 points in the MIPS APM scoring model. The cost category has a weighting of zero percentage points in the MIPS APM scoring model.
   • Individual clinicians and groups are required to submit their promoting interoperability (formerly advancing care information) performance data, and this is the only MIPS-related reporting requirement for the practice. The ACO or another entity will summate the performing interoperability data generated by the electronic health records.
2. Question: For clinicians in an APM what are the weighting of the MIPS performance categories?
   • The MIPS APM relative weightings for the four MIPS categories are Quality: 50%,  Promoting Interoperability: 30%, Improvement Activities: 20% and Cost: 0%
3. Question: Can clinicians elect to opt out of being in a MIPS APM and report directly under the MIPS scoring model (i.e., as if they were in the MIPS but not participating in an ACO)?
   • At this time all clinicians on APM participation lists that meet certain requirements do not have the option of opting out of having their data reported via their MIPS APM entity.  However, CMS (personal communication in June 2018) is evaluating changes to this model that may allow clinicians that are currently obligated to report via their MIPS APM entity to opt out of reporting via the MIPS APM and instead report directly to CMS as a MIPS eligible clinician or group, using the MIPS scoring methodology.