MACRA and MIPS Part II: Reporting

Now that the final rule for the Quality Payment Program has been passed under MACRA, the new Medicare payment program have begun to go into effect. MACRA and the Quality Payment Program have become one of the main discussion topics among physicians and healthcare professionals.

How do you qualify for MACRA and the Quality Payment Program?

In order to qualify for MACRA and to report under one of the payment programs, a clinician must bill more than $30,000 to Medicare patients, and provide care for more than 100 Medicare patients each year. These individuals must also be in one of the following healthcare fields:

  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetists

The first performance period for the new Quality Payment Program (QPP) began in January 2017 – but there’s still time to participate. In order to be considered for the 2019 adjustment year, you must begin your data collection by October 2, 2017, and submit all performance data by March 31, 2018. The data collected will be used for the adjustment year that will begin on January 1, 2019.

One of the most important steps a clinician can take to prepare for the QPP is to ensure your electronic health record system is certified by the Office of the National Coordinator for Health Information Technology (ONC). All EHRs certified by the ONC should be able to capture the required data.

“… [T]the bedrock of the Quality Payment Program is high-quality, patient-centered care followed by useful feedback, in a continuous cycle of improvement” –The Centers for Medicare & Medicaid Services


One of the two reporting tracks under the QPP is called the Merit-based Incentive Payment System (MIPS).  Clinicians who prefer to stay with the traditional Medicare Part B payment program should choose to participate in the MIPS track of the QPP.  As we discussed in our previous blog post on MACRA and MIPS, the new formula for Medicare B payment adjustment under MIPS will consist of four performance categories. Either an individual or a group can report their performance data to the CMS. However, each will have different forms of reporting required.

As discussed earlier, an essential part of reporting under MIPS will be to have an electronic health record system certified by the ONC. One of the goals of MIPS is to encourage the widespread use of electronic clinical quality measure (eCQM) reporting. This will be achieved by using APIs (application programming interfaces) to allow the interoperability of healthcare and information software with an EHR. With APIs, patients and clinicians can use smartphone apps to access medical information from other programs (other than just an EHR), which is a key initiative for the CMS to make electronic health information available when and where it matters most.

It will be important for clinicians to correctly utilize their EHR data and reporting capabilities, to ensure high quality information is submitted under the Advancing Care Information, Quality and Improvement Activities of the MIPS performance categories. The ONC listed certified health IT objectives for each of these categories.

Reporting Under MACRA

The objectives hope to achieve a new healthcare system in which “certified EHRs and health IT [are used] as tools to improve the flow of health information among clinicians and, ultimately, improve the quality of care provided to patients” (ONC).

Clinical Practice Improvement Activities (CPIA)

The Centers for Medicare and Medicaid Services provides a list of activities that qualify as a CPIA. Each of the activities listed will have one of two different weights assigned to it. CPIAs can have either a “high” weight or a “medium” weight, earning 20 or 10 points each, respectively. In order to achieve full credit under the Clinical Practice Improvement Activities, a clinician must submit a total of 60 points. The performance activities under CPIA will all fall within one of eight proposed subcategories:

  • Expanded Access to Care
  • Population Management
  • Care Coordination
  • Beneficiary Engagement
  • Patient Safety & Practice Assessment
  • Achieving Health Equity
  • Emergency Response & Preparedness
  • Integrated Behavioral & Mental Health

MOC Part IV, for example, falls under the subcategory Patient Safety & Practice Assessment. The activity weight is 10 points, or a “medium” weight. MOC Part IV can be fulfilled in a variety of ways. One way is for a clinician to join a local, regional or national outcomes registry or quality assessment program. To participate, a clinician must document performance of monthly activities across their practice, and regularly assess their performance. The performance data is then reviewed to identify areas in their practice that could be improved upon, which is followed by creating activities designed to improve performance in that area. Another way is for the clinician to create the MOC Part IV activities themselves, and to have their documentation and improvement activities approved by an accredited portfolio provider.

Clinicians who have found documenting and creating improvement activities to be tedious and time consuming have turned to performance improvement platforms to assist them. Performance Improvement platforms are designed to document and track clinicians’ practice, assess them to identify areas in need of improvement, and make intelligent recommendations for learning to address gaps. Performance Improvement platforms may be provided by a healthcare provider or by a professional society.

The data collected from completing MOC Part IV can be submitted to the Centers for Medicare and Medicaid Services by attestation, a Qualified Clinical Data Registry (QCDR), a Qualified registry, an EHR or by administrative claims if technically feasible (no submission required). At Web Courseworks, we see a need to for CME and performance improvement platforms to automate reporting on CPIAs to EHRs and government platforms in order to reduce the administrative burden on clinician learners.


Attending AAMSE 2017? We’re exhibiting! Stop by booth #5 to discuss MACRA & MIPS. We’re looking forward to learning about further developments in healthcare laws and continuing education. We’ve also made a note of 3 topics for medical execs to watch.