MIPS: An Overview of Reporting and Scoring for the Performance Year

Posted on  June 29, 2017



In 2017, approximately 600,000 eligible clinicians across the United States will be affected by MACRA. If you’re one of them, the information you have been provided about the new legislation is more than likely a bit distressing. Whether you’re in the MIPS payment track or participating in APMs, there is more than enough information to wrap your head around. We’re going to attempt to help you maneuver through the information favorably so that you can strengthen your practice and earn as many incentives as possible.
Reporting For The Performance Year


You’ve heard by now that clinicians participating in the MIPS payment track have choices. Whether or not you choose to test, participate for 90 days, or collect data for the full year will have bearing on what your reporting requirements are. Here’s a quick synopsis for each option.

1. Testing: This is, of course, the easiest option available to all eligible clinicians participating in the MIPS payment track. This option requires you to choose any day that occurs in 2017 in which you treated a minimum of 20 patients. Next, you will run a report based on the relevant information for either 1) One Quality Measure; 2) One Improvement Activity; or 3) All required measures in the Advancing Care Information Category.
2. 90 Consecutive Days: This option is most similar to the full-year option in that you will still collect all data required by three (3) categories of the MIPS Payment Track. Those categories are 1) Quality; 2) Improvement Activities; and 3) Advancing Care Information. The benefit this option allows you is a little more time to choose the measures and activities that are most relevant to your practice. We’ll talk more about choosing those categories in a minute. If this is the option you choose, you can wait to get started as late as October 2nd, 2017 and still have a full 90 days of data to collect.

3. Full Year of Data: Just like option two (2), you must collect all data for the same three measures. However, the data should be collected for every day between January 1st, 2017 through December 31st, 2015. If you choose this option, you should have already made sure that you were documenting the relevant information for the measures and activities you chose.

If you have not decided which information to report, CMS has set up an easy to use tool for choosing the Quality Measures and Improvement activities. They’ve also set up a page that shows you exactly how to meet the measures of the Advancing Care Information category. Here are the links to those tools.

1. Quality Measures: Use this search engine to pare down the 274 Quality Measures to a much more reasonable size. There are several filter types that will help you find the measures that are most relevant to your practice. Here is a link to the search engine: Choose Quality Measures.

2. Improvement Activities: Depending on the size of your practice you will choose two (2) to four (4) improvement activities to report for the first performance year. Those practices with 15 or fewer clinicians only need to choose two (2). You can find the search engine here: Improvement Activities.

3. Advancing Care Information Category: Based on the year your certified EHR received its certification, you will have 2 options under this category. Those options are 1) Advancing Care Information Objectives and Measures, and 2) 2017 Advancing Care Information Transition Objectives and Measures. You will report for Option 1 if you have technology certified to the 2015 Edition or if you have a combination of technologies from 2014 and 2015 Editions that support these measures. You will report for Option 2 If you have technology certified to the 2015 Edition, or If you have technology certified to the 2014 Edition; or If you have a combination of technologies from 2014 and 2015 Editions. This category is much simpler and if you’ve ever attested for Meaningful Use in the past, you’re already a pro. Simply choose your option, then follow the instructions for that option. You must attest for each measure as it is laid out. You will find both options here: Advancing Care Information.

One final thing to note about reporting is that regardless of the option you chose, reporting begins on January 1, 2017, and the deadline is March 31, 2018.

Now let’s talk about scoring. Once again, depending on what reporting option you’ve chosen, your score is calculated accordingly. Here is an overview:

1. Test Score: This option is not scored at all. In short, by sending in the appropriate data you will avoid a negative payment adjustment altogether. You will not, unfortunately, be eligible for any type of positive payment adjustment or bonus incentives.

2. 90 Consecutive Days and Full Year Reporting: These options are scored exactly the same way. For the Quality Category, each measure will earn up to 10 points. For the Improvement Activities, the score you can achieve is based on the weight of the measure. High weighted activities are worth 20 points. Medium-weighted activities are worth 10 points. Finally, the Advancing Care Information category calls for you to complete the required measures but allows you to earn bonus points by using a certified EHR for your Improvement Activities or by reporting to additional registries aside from the Immunization registry.

After your score has been calculated for each category they take their relative weights and add them together to determine your Total Composite Performance Score. The Quality Category counts for 60%, the Advancing Care Information counts for 25% and the Improvement Activities Category counts for 15%. Once each weight is applied, they are added together and this is your score. How much your positive payment adjustment is, depends on where you rank compared to all other eligible clinicians. Finally, the top 25% will be eligible for a bonus payment of up to 10%. This will depend on where you rank in the top 25%.

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