Gastroenterology Coding Alert

Question: How does quality reporting under MACRA relate to earlier programs such as PQRS, EHR, and VM?

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Answer: Before MACRA, Medicare paid physicians based on a fee-for-service structure called the Sustainable Growth Rate. However, CMS had instituted several quality reporting initiatives in recent years, such as Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) incentive program called “Meaningful Use,” and Value-Based Payment Modifier (VBM).

These began as voluntary programs and varied in payment impact from neutral, to small incentives, to penalties. In fact, eligible clinicians who didn’t report to PQRS for 2016 services can expect a two percent payment reduction from Medicare Physician Fee Schedule rates in 2017 and four percent for 2018.

Under MACRA, CMS phases out data collection for any of the previous programs for services beginning Jan. 1, 2017 (although data reporting from performance-year 2016 continues to affect payments made for 2018 services). Instead, you’ll have a new Quality Payment Program (QPP) with two paths: Advanced Alternative Payment Model (APMs) (which most practices won’t qualify for this year), or Merit-Based Incentive Payment System (MIPS).

Important:  Eligible clinicians must report data for MIPS in 2017 or face payment penalties in 2019. MIPS aims to evaluate performance under four categories, three of which parallel the three terminated programs, as follows:

• Quality — primarily replaces PQRS
• Advancing Care Information — primarily replaces Meaningful Use of EHR
• Cost — primarily replaces VM
• Improvement Activities — new quality category for evaluation.

Clinicians will receive a score in each category, which CMS weights according to the relative importance assigned to each, to arrive at a single score between 0 and 100. The category weight may change over time and based on clinician characteristics. See the CMS Quality Payment Program site at https://qpp.cms.gov/.