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MACRA and MIPS and APMs…Oh My!

Amy Ochier, RHIA, CMA(AAMA)

Instructor, Medical Assisting Program

Terra State Community College

Previous Reimbursement Models

• Multiple individual quality and value programs for Medicare Part B reimbursement for physicians and practitioners including:

• Physician Quality Reporting System (PQRS)

• Value-Based Payment Modifier

• Medicare Electronic Health Record (EHR) Incentive Program

• MACRA streamlines previous programs

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Learning Objectives• Define acronyms associated with MACRA

• Differentiate between MIPS and APMs

• Define and describe the four components of a MIPS score

• Discuss the role of HIM and Medical Assisting Professionals in reporting quality indicators

• Identify the advantages and disadvantages of MACRA for different types of providers

What is MACRA?

• The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)• Signed into law on April 16, 2015• Includes five titles

• Title I• Repealed the sustainable growth rate (SGR) formula• Established the Quality Payment Program (QPP)

• Title II• Extended funding for the Community Health Centers Fund

(CHCF)• Extended multiple expiring provisions in Medicare, Medicaid,

and other programs

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What is MACRA?

• The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)• Includes five titles

• Title III• Extended funding for the state Children’s Health Insurance

Program (CHIP)• Title IV

• Medicare program changes to offset the cost of repealing the SGR

• Title V• Provisions related to Medicare program integrity

• Prohibits Social Security numbers on beneficiaries’ Medicare Cards

Acronyms Associated with MACRA

MACRA and MIPS and APMs… Oh My! Acronyms and their meanings to help you

navigate the yellow brick road.

Acronym Meaning

MACRA The Medicare Access and CHIP Reauthorization Act of 2015

QPP Quality Payment Program

APMs Alternate Payment Models

MIPS Merit-based Incentive Payment System

ACO Accountable Care Organization

SGR Sustainable Growth Rate

CMS Centers for Medicare and Medicaid Services

QPs Qualifying (APM) Participants

MSPB Medicare Spending per Beneficiary

TPCC Total Per Capita Cost

ACI Advancing Clinical Information

QCDRs Qualified Clinical Data Registries

IA Improvement Activities

CEHRT Certified Electronic Health Record Technologies

HCC Hierarchal Condition Classification

TINs Taxable Identification Numbers

CPC+ Comprehensive Primary Care Plus

IGAM (AHIMA’s) Information Governance Adoption Model

API Application Programing Interface

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MIPS vs APMs

• Clinicians participate in one of two QPPs under MACRA

• Advanced Payment Model (APM)

• Merit-based Incentive Payment System (MIPS)

• Quality

• Improvement Activities (IA)

• Advancing Care Information (ACI)

• Cost

MACRA

QPP

APMs MIPS

Quality

IA

ACI

Cost

MIPS vs APMs

• Merit-based Incentive Payment System (MIPS)• Score is determined by weighted categories

• Alternate Payment Models (APMs)• New approaches to paying for medical care that incentivize quality and value• APM eligible categories differ each reporting year

• Includes most Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) tracks

• Scores will be calculated by taking an average of all clinicians in the APM• Clinicians that are part of an APM that are not a Qualifying Participant

(QP) will receive favorable scoring under MIPS

• The majority of clinicians will be in the MIPS model for the first few years of the QPP

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Components of a MIPS Score

• Quality – about 271 reporting measures

• Improvement Activities – 112 activities

• Advancing Care Information – no longer pass/fail

• Cost – will be compared to other clinicians, not previous year

* 2018 MIPS Performance Year will determine payment adjustments for 2020

Components of a MIPS Score: Quality

• Replaces PQRS

• Report on up to 6 quality measures

• About 271 quality measures to choose from

• Must include at least 1 outcome measure

• If none applicable, then report a high priority measure

• Examples of Quality Measures

• Outcome measure

• High priority measure

• Neither outcome or high priority measure

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Components of a MIPS Score: IA

• New category

• Choose from 112 Improvement Activities

• Reporting requirements vary

• Most participants report 4 IAs completed

• Groups with fewer than 15 participants or in a rural or health professional shortage area report 2 IAs completed

• Participants in PCMH automatically earn full credit for this category

• Examples of Improvement Activities

Components of a MIPS Score: ACI

• Replaces the Medicare EHR Incentive Program, also known as Meaningful Use

• Required reporting on 5 Advancing Care Information measures• Additional credit for reporting on up to 9 ACI measures

• Certified EHR Technologies (CEHRT) used for reporting• 2018 reporting – 2014 and 2015 Editions

• 10% bonus for 2015 Edition• 2019 reporting – 2015 Edition required

• Hardship Exception – reweighting of category to 0%

• Examples of ACI measures

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Components of a MIPS Score: Cost

• Replaces the Value-based Modifier

• Based on the Medicare Spending per Beneficiary (MSPB) and Total Per Capita Cost (TPCC)

• Only used if the minimum is met

• If both measures are met, an average is taken

• If only one is met, it is used

• If neither is met, Cost is reweighted to 0% and 10% is shifted to Quality

Components of a MIPS Score

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MACRA Timeline

Reporting and Payment Adjustment Schedule

Year Data is Reported Year Payment is Adjusted Adjustments

2017 2019 +/- 4% (bonus up to 12%)

2018 2020 +/- 5% (bonus up to 15%)

2019 2021 +/- 7% (bonus up to 21%)

2020 2022 +/- 9% (bonus up to 27%)

2021 2023 +/- 9% (bonus up to 27%)

2022 2024 +/- 9% (bonus up to 27%)

2023 2025 +/- 9% (bonus up to 27%)

2024 2026 +/- 9% (bonus up to 27%)

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Role of HIM and MA Professionals

• Determining which clinicians are eligible for MIPS in their organization• All physicians and advanced practice providers • Exclusion criteria:

• Total annual Medicare Part B $30,000 or less• Total annual number of Part B encounters is 100 or less• Clinician is newly enrolled during the performance year• Clinician is Qualified or Partially Qualified Advanced APM participant

• Hospital-based Clinicians• Patient facing – based on previous year’s claim data• Non-patient facing – 100 or fewer patient facing encounters

• Reweighting of MIPS categories may occur

Role of HIM and MA Professionals: Reporting Strategies• Advanced APM Participation (if available)

• QPs are excluded from MIPS payment adjustments

• MIPS scores are not published on Physician Compare

• 5% lump sum payment for first six years of the QPP

• APMs will become increasingly selective

• High MIPS scores may indicate potential high performance in APMs

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Role of HIM and MA Professionals: Reporting Strategies• Full Participation in MIPS during 2018

• Quality and Cost categories are the challenge

• Quality

• Detailed assessment of measurements

• Data completeness of 60% is required

• Clinician and staff education

• Analysis and intervention for negative trends

• Cost

• Risk adjustment scores

• ICD-10-CM coding completeness and specificity

• HCC coding determines the complex patient bonus

Role of HIM and MA Professionals: Reporting Strategies• Goal MIPS score of 15 or more

during 2018

• Practices that are not prepared or do not have the resources for full participation

• Avoids negative payment adjustments

• Does not give the experience needed to do well in future years

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Trends so far…• MIPS performance threshold score (neutral payments)

• 2017 – 3 pts

• 2018 – 15 pts

• 2019 – data suggests about 78 pts

• Below threshold score ranges for 2018

• 0 – 3.75 pts: maximum negative payment adjustment (-5%)

• 3.76 – 14.99 pts: proportional negative payment adjustment (-4 to -0.1%)

• CMS estimates between 2.9 to 4.7% of clinicians will receive a negative payment adjustment

• Above threshold score ranges will result in a positive payment adjustment that will be determined in late 2019

Trends so far…

• 2019 will bring a significant change

• Below projected threshold score (78 pts) ranges for 2019

• 0 – 19.5 pts: maximum negative payment adjustment (7%)

• 19.6 – 77.9 pts: proportional negative payment adjustment (-6.9 to -0.1%)

• Unknown amount of clinicians, but is projected to be much higher

• Above threshold score ranges will result in a positive payment adjustment that will be determined in late 2020

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Estimated MIPS Payment Adjustments in 2020 Based on 2018 Performance Scores

Estimated MIPS Payment Adjustments in 2021 Based on 2019 Performance Scores

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Estimated MIPS Payment Adjustments in 2022 Based on 2020 Performance Scores

Provider Advantages and Disadvantages

• Advantages

• Clinicians can choose to report individually or as a group

• Groups report under a single Taxpayer Identification Number (TIN)

• Group reporting lowers administrative burden and costs to individual clinicians

• Groups containing different specialties will have to pay closer attention to performance to ensure the measures reported are those that a majority of clinicians have positive outcomes

• Activities routinely performed such as care coordination and patient engagement will now be rewarded

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Provider Advantages and Disadvantages

• Disadvantages• Increase in services for

specialties• Work at the top of their

licenses• See more patients with

multiple morbid conditions• Turn over management of

routine patients to advanced practice providers

• No adjustment for treating patients with high-risk social factors

Provider Advantages and Disadvantages

• Disadvantages

• Patient relationship codes

• Reflect physicians’ responsibility to patients at the time of service

• Additional modifier for each billed service

• Not an accurate reflection of the role some clinicians, such as radiologists, play in the medical decision making process

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Summary

• The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) streamlines previously used Medicare Part B reimbursement systems into the Quality Payment Program (QPP)

• Providers can choose to participate in an Advanced Payment Model (APM) if eligible

• Those not participating in an APM will participate in the Merit-based Incentive Payment System (MIPS)

Summary

• MIPS consists of reporting 4 weighted categories:• Quality

• Improvement Activities (IA)

• Advancing Care Information (ACI)

• Cost

• As MACRA is being implemented the weighting of the categories will change each year

• Scores for each reporting year will affect the reimbursement rates for the claims submitted the year following the year the score is determined (2 year process)

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Summary

• HIM and MA professionals will play a central role with MACRA• Accurate documentation and coding• Data analytics and quality

improvement• Determining clinician eligibility and

reporting strategy

• There are both advantages and disadvantages for clinicians• Group or individual reporting• Increase in services for specialists• Patient relationship codes

References

Bradshaw, S., Krause, D., & Marron-Stearns, M. (2017). MIPS APMs and how they may impact your MACRA strategy. Journal of AHIMA 88(9), 22-25.

Hirsch, J., Rosenkrantz, A., Ansari, S., Manchikanti, L., & Nicola, G. (2017). MACRA 2.0: Are you ready for MIPS? Journal of NeuroInterventional Surgery, 2017(9), 713-715. doi:10.1136/neurintsurg-2016-012845

Marron-Stearns, M. (2017). How MACRA changes HIM. Journal of AHIMA 88(3), 22-25.

Marron-Stearns, M. (2018). MACRA strategies for 2018 and 2019. Journal of AHIMA, 89(2), 22-27. Retrieved from http://bok.ahima.org

McWilliams, J. M. (2017). MACRA: Big fix or big problem? Annals of Internal Medicine, 167(2), 122-124. doi:10.7326/M17-0230

Rosenkrantz, A., Hirsch, J., & Nicola, G. (2017). Radiology and the new medicare/MACRA patient relationship codes. Journal of the American College of Radiology, 14(9), 1180-1183. https://doi.org/10.1016/j.jacr.2017.01.054

Walsh, M. (2017). MACRA is law: Practice transformation is the goal. Journal of the American College of Cardiology, 70(8), 1096-1098. doi:10_1016/j_jacc.2017.07.720

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Question and Answers