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Quality Payment Program

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Quality Payment Program (as Required by MACRA)

The Centers for Medicare & Medicaid Services (CMS) began the Quality Payment Program (QPP) on January 1, 2017  under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which requires implementation of an incentive program to pay Medicare-participating clinicians for high quality, value-based care. As a result, the QPP was established as the newest iteration to reward healthcare providers for high quality, low cost, and efficient healthcare. The QPP is composed of two tracks: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMS). CMS provided an infographic of the 2019 QPP Performance year for clinicians. ID physicians may choose which track to participate in based on practice size, location, or patient population. In general, most ID physicians will participate in the MIPS. For more information on your MIPS eligibility, please enter your 10-digit National Provider Identifier (NPI) within the  CMS QPP Participation Status tool.

QPP Resources 

In an effort to educate our members, IDSA sponsored a webinar to provide practical information that ID physicians may need when participating in the QPP. The slides are available to download here. Recently, CMS released the FY2019 Physician Fee Schedule and Quality Payment Program final rule. On behalf of our members, IDSA submitted a comment letter to CMS. The letter can be viewed under the Key Resources.

In addition, the American Medical Association (AMA) prepared several resources to help physicians and their staff prepare for participation in the QPP. The AMA has podcasts, learning modules, and webinars to view here

The Merit-Based Incentive Payment System (MIPS) is a performance-based payment program for clinicians that bill under Medicare Part B and meet the low-volume threshold requirements implemented by CMS. IDSA prepared a QPP participation and eligibility document for our members, to outline the criteria for participating in the MIPS track. Clinicans are evaluated based on four separate quality categories:

  • Quality: The quality component of MIPS will be used to evaluate the quality of care that is provided by participating clinicians. The quality measures are based on patient outcomes and the healthcare process. This performance measure is 50% of the MIPS final score. Participants are required to submit data for a 12 month period on 6 quality measures. If participants are apart of a group pratice of twenty-five or more clinicians, CMS requires submission of data on all 15 quality measures. 
  • Improvement Activities: Improvement activities are activities or programs that may improve clinical practice or care delivery, and that will likely result in improved patient outcomes. This performance category accounts for 15% of the MIPS final score and requires a 90-day or more data collection period.
  • Promoting Interoperability: The Promoting Interoperability category (formally known as the Advancing Care Information category) measures patient engagement and usage of a certified electronic health record technology (CEHRT) system to exchange information. The 2015 edition of CEHRT are eligible to participate in the 2019 performance year. However if participants do not meet the requirements for this category, CMS required submission of the Hardships Exception Application. This performance category accounts for 25% of the MIPS final score. If this category is not applicable the 25% will be reallocated to another performance category.
  • Cost: MIPS uses cost measures to assess the total cost of care during a 12-month period, hospital stay or after 8 episodes of care. Clinicians are not required to submit data for this category. CMS will collect data from Medicare claims. Participants are evaluated and scored based on 10 cost measures, which will account for 15% of the MIPS final score.

The physician’s performance in each of the four categories will be used to create a composite score upon which the physician’s overall performance will be assessed. The Explore Measures tool  provided by CMS can be used to determine specialty-specific quality measures in each category that are best for your practice.

 It is important to note that for hospital-based physicians, defined as a MIPS eligible clinician who furnishes 75 % or more of his or her covered professional services in sites of service for inpatient, hospital, campus outpatient hospital, or the emergency room, will have a higher proportion of their performance based on quality due to re-weighting of the promoting interoperability category. This is due to the fact that hospital-based clinicians have little to no control over the use or type of the electronic health records systems that their employer uses. IDSA has provided some basic information to assist ID physicians in meeting the requirements of the new QPP.

The Advisory Board Company has created a guide for physicians participating in MIPS. Of note is the section of the presentation starting on slide 54, whereby the Medicare patient attribution methodology is described; this will help ID physicians to be aware of how patients are attributed when it comes to calculating a quality score. The presentation is available here: Medical Group Success Under MACRA

To satisfy the reporting requirements of the quality category for MIPS in 2017, eligible clinicians or a group practice must report quality data on six measures. Of the six measures, one must be an outcome measure. In cases where an outcome measure is not available for a participating clinician, a high-priority measure can be reported as a substitute. A high-priority measure is defined as an outcome, appropriate use, patient experience, patient safety, efficiency, or care coordination measure.

IDSA is aware of the lack of applicable quality measures to the ID physician and has voiced concerns to CMS regarding this troubling issue. IDSA is currently exploring initiatives to address the inappropriate evaluation of ID physicians by reviewing the feasibility of developing an IDSA-sponsored clinical data registry to promote the value of the ID physician. In the short term, as payment adjustments are increasing, -4% payment penalty for non-participation in MIPS for 2017, IDSA recommends members to report on the following measures to avoid the payment penalties, (Note: the measures indicated below assume that an ID physicians sees patients in the outpatient and inpatient setting. Those shown in bold below only apply to the outpatient setting).

IDSA Recommendation for Reporting Six Quality Measures:

  • Measure #110: Preventive Care and Screening Influenza Immunization: Community/Population Health (Claims, EHR, CMS Web Interface, Registry)
  • Measure #111: Pneumococcal Vaccination Status for Older Adults: Community/Population Health (Claims, EHR, CMS Web Interface, Registry)
  • Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Community/Population Health (Claims, EHR, CMS Web Interface, Registry)
  • *Measure #130: Documentation of Current Medications in the Medical Record -- High-Priority Measure; National Quality Strategy Domain: Patient Safety (Claims, Registry, EHR, GPRO Web Interface, Measure Groups)
  • Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Community/Population Health (Claims, EHR, CMS Web Interface, Registry)
  • *Measure #407: Appropriate Treatment of Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia -- High-Priority Measure; National Quality Strategy Domain: Effective Clinical Care (Claims, Registry)

*Indicates high-priority measures

Inpatient Opportunities to Report

There are a limited number of MIPS measures applicable to those clinicians who practice in the inpatient setting and rely largely on initial and subsequent hospital visit codes. Provided below is a list of these measures for 2017.

Note: In order to ensure compliance in the Quality component of MIPS, ID physicians should report on #130 – Documentation of Current Medications in the Medical Record as a standard practice incorporated in a typical inpatient E&M encounter. The specification language for measure #130 indicates that this measure should be done at each visit, however, only the initial patient encounter CPT codes apply to this measure. As well, some ID physicians may feel that reporting measure #47 - Care Plan may be appropriate for some patient cases. Please be aware that once a provider starts reporting any quality measure, CMS will expect that the provider will report the measure for at least 50% of the cases. Therefore, should an ID physician report measure #47 for an initial or subsequent inpatient visit, then that physician will be expected to report measure #47 for at least 50% of the initial and subsequent patient visits for which they bill. Please see the MIPS quality measure specifications for the specific requirements for each mentioned measure (.zip – 249.3MB).

Applicable Measures for 99221 - 99223:

  • Measure #1 (NQF 0059): Diabetes: Hemoglobin A1c Poor Control -- National Quality Strategy Domain: Effective Clinical Care (Claims, Registry)
  • Measure #47 (NQF 0326): Care Plan -- National Quality Strategy Domain: Communication Care Coordination (Claims, Registry)
  • Measure #130: Documentation of Current Medications in the Medical Record -- National Quality Strategy Domain: Patient Safety (Claims, Registry, EHR, GPRO Web Interface, Measure Groups)
  • Measure #407: Appropriate Treatment of Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia -- National Quality Strategy Domain: Effective Clinical Care (Claims, Registry)

For subsequent inpatient face-to-face encounters, CMS has identified three quality measures that are applicable, which are listed below. As stated above, there are times when an ID physician may discuss Advanced Care Planning with a patient. Should the ID physician want to report this as a quality measure, they should be aware that CMS will expect that they report it on at least 50% of the subsequent visit codes for which they bill.

Applicable Measures for 99231 - 99233

  • Measure #1 (NQF 0059): Diabetes: Hemoglobin A1c Poor Control -- National Quality Strategy Domain: Effective Clinical Care (Claims, Registry)
  • Measure #47 (NQF 0326): Care Plan -- National Quality Strategy Domain: Communication Care Coordination (Claims, Registry)
  • Measure #407: Appropriate Treatment of Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia -- National Quality Strategy Domain: Effective Clinical Care (Claims, Registry)

If an individual clinician is submitting quality data by the claims-based submission method, CMS has developed a claims measures single source identifier tool. This can assist clinicians in identifying potentially applicable quality measures for reporting by searching for diagnosis and/or encounter code. Please see the 2018 MIPS Individual Claims Measure Single Source Tool (.xls).

Clinical Practice Improvement Activities

As a part of the MIPS, CMS will also measure the use and reporting of clinical practice improvement activities, which is a new quality measurement category. Improvement activities are activities (such as expanded practice access) or programs (such as antibiotic stewardship) that may improve clinical practice or care delivery and that will likely result in improved outcomes.

Under the new MIPS program, providers can chose from a list of 90+ improvement activities (IAs) in order to meet the requirements of the improvement activity category. IDSA has prepared a list of improvement activities that ID physicians may wish to report. For the first year of the program, in order to avoid a penalty, a provider only needs to report and attest to one improvement activity. CMS has not released any guidance on the specific types of activities that will fall under each subcategory of improvement activities, therefore IDSA encourages physicians to review the entire list of improve activities and chose activities that may be applicable to your type of practice. The complete list of improvement activities is available from the Quality Payment Program website.

Providers will need to attest that an improvement activity was performed. CMS has stated that while they’re not requiring physicians to submit any documentation to prove an AI was completed, physicians are encouraged to retain medical records or any other data used to support/determine the completion of the activity for up to 10 years following the performance period.

CMS to Study the Use and Reporting of Improvement Activities

CMS is conducting a Clinical Practice Improvement Activity study to gain a better understanding of how practices and providers will be affected by the new quality category of improvement activities. Those providers and practices who participate in the study will receive full credit for the improvement activities category in the MIPS program. Applications for participation in the study are due January 31st, 2017. To apply to participate in the study, visit the Clinical Practice Improvement Study Information website.

Example of MIPS Clinical Practice Improvement Activities

  • Patient Safety and Practice Assessment: Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics
  • Expanded Practice Access: Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults, or teleaudiology pilots that assess ability to still deliver quality care to patients.
  • Emergency Response and Preparedness: Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.
  • Population Management: Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/or conduct periodic, structured medication reviews.
  • Population Management: Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.
  • Population Management: Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Additional Resources

CMS developed the 2017 QPP Experience Report  and provided an appendix of specialty specific qualtiy improvement activities. If you have questions or need assistance with MIPS reporting please contact the Quality Payment Program Service Center. 
The help desk is available Monday – Friday; 8:00 AM–8:00 PM ET:
Phone: 1-866-288-8292 TTY: 1-877-715-6222 Email:

Alternative Payment Models (APMs) provide an opportunity for clinicians that are not participating in the MIPS track to receive incentives for providing high-quality, cost-efficient care.  AMPs can be subdivided into 3 main payment categories: MIPS APMs,  Advanced APMs, and  All-payer Advanced APMs.

  • Typically, clinicians that do not meet the low volume threshold, which is required to participate in the MIPS track are by default, participants of MIPS APM.
  • CMS will assign a performace cateorgy to participants and participants will be required to submit data on the performace cateogory.
  • CMS bases payment on MIPS performance categories with APM scoring standards:  50% Quality, 20% Improvement Activities and 30% Promoting Interoperability.
  • Allows participation in the APM incentive program however, participants are not subjected to financial risk associated with APMs.
Advanced APMs
  • Requires usage of a certified Electronic Health Record (EHR) system
  • Payments are based on quality measures that compare to one of the four MIPS quality categories
  • Advanced AMPs allow medical practices to earn a 5% incentive payment for taking on some risk related to patients’ outcomes. Physicians can earn this 5% bonus in 2019 if they receive 25% of their Medicare Part B payments through an Advanced APM or if they see 20% of their Medicare patients through an Advanced APM.
All-payer Advanced APMs
  • eligible clinicans must participant in both Medicare APM and commerical or private payer APMs.
  • CMS requires other payers to submit payment arrangements and providers other payers with performance period requirements.
  • Clinicans may experience a greater financial risk if the total expeditures are higher than expected.


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