Merit-Based Incentive Payment System (MIPS)

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Merit-Based IncentivePayment System (MIPS)Resource GuideNovember 3, 2016CONTENTSSection 1. MIPS and Who It Applies To.2Section 2. Preparation Checklist.4Section 3. Quality Performance Category (60%).7Section 4. Cost Performance Category (0%). 13Section 5. Advancing Care Information Performance Category (25%). 14Section 6. Improvement Activities Performance Category (15%). 17Section 7. MIPS Reporting Mechanisms. 20Section 8. Additional Resources. 201

SECTION 1MIPS and Who It Applies ToThe Medicare and CHIP Reauthorization Act (MACRA) of 2015 created sweeping reforms to reimbursementto providers under Medicare Part B and establishes a new Quality Payment Program. The Quality PaymentProgram outlines two pathways for payment for providers who participate in Medicare Part B: AdvancedAlternative Payment Models and the Merit-Based Incentive Payment System (MIPS). The vast majority ofproviders will be reimbursed under MIPS in 2017. This MIPS Resource Guide includes a readiness checklist,details related to the performance reporting categories, and information on the specific reporting optionsavailable to providers.All of the information provided in this MIPS Resource Guide is based on detail in final rulemaking issuedby the Centers for Medicare and Medicaid Services on October 14, 2016.About MIPSMIPS-Eligible CliniciansMIPS collapses three existing quality reportingprograms into one, while adding a fourth category:Eligible clinicians during the 2017 reportingyear include physicians (including psychiatrists),nurse practitioners, physician assistants, clinicalnurse specialists and nurse anesthetists who billMedicare Part B using the physician fee schedule. The Physician Quality Reporting System (PQRS)becomes Quality under MIPS, and assesseseligible clinicians on their performance on at leastsix quality measures The Value-based Payment Modifier Program(VM) becomes Cost under MIPS, and comparescosts to treat similar care episodes and clinicalcondition groups across practices The Medicare Electronic Health Record (EHR)incentive program becomes Advancing CareInformation under MIPS, and retains an emphasison interoperability and information exchange A brand-new reporting area is ImprovementActivities, which rewards practices that engagein quality improvement activities, including fortheir Medicaid and other non-Medicare patientpopulationsEach of the four categories listed above are weightedand collectively form a final score from 0-100. CMSwill set a performance threshold every year andcompare eligible clinicians’ and group’s scores tothe threshold to determine payment adjustmentsIn 2017, MIPS does NOT apply to: Clinical psychologists & licensed clinical socialworkers (LCSWs) First-year Medicare providers Qualifying Advanced APM clinicians Hospitals and facilities (e.g., skilled nursingfacilities) that do not bill medicare using thePhysician Fee Schedule Clinicians who fall beneath CMS’s low-volumethreshold, who serve fewer than 100 Medicarerecipients OR bill Medicare 30,000 or less peryear Clinicians and groups who are not paid underthe Physician Fee Schedule (e.g., FQHCs andpartial hospitalization programs); MIPS alsodoes not apply to Managed Care paymentsAlthough they are not considered eligible in 2017,the final rule states that additional clinicians,including psychologists and LCSWs, may be eligibleto report to MIPS in 20192

MIPS Scoring and 2019 Payment AdjustmentsPerformance CategoriesCMS will score each MIPS eligible clinician or group according to four performance categories in 2017.Each category will be weighted differently:CMS will use these weighted scores to calculate a final score between 0-100. CMS will use this scoreto determine positive, neutral and negative payment adjustments in 2019. Payment adjustments areexpected to increase every year, from /- 4.0% in 2019 to /-9.0% in 2022.Reporting Options: “Pick Your Pace”In September 2016, CMS announced that MIPS eligible clinicians will have three reporting options to avoid anegative payment adjustment in 2019: Option 1: Test the Quality Payment Program. As long as you submit some data via MIPS, including datafrom after January 1, 2017, you will avoid a negative payment adjustment. This option is designed to ensurethat your system is working and that you are prepared for broader participation in 2018 and 2019.3

Option 2: Participate for part of the calendar year. You may choose to submit MIPS data for at least 90consecutive days in 2017. This means your first performance period could begin later than January 1, 2017and your practice could still qualify for a small positive payment adjustment. Option 3: Participate for the full calendar year. For practices that are ready to go on January 1, 2017,you can choose to submit MIPS data information for the full calendar year. This means your first performanceperiod would begin on January 1, 2017.SECTION 2Preparation ChecklistStart NOW and Keep Going1Determine if you’re eligible for MIPS. As an individual clinician, are you below the low-volume threshold of seeing 100 or fewerMedicare patients OR billing Medicare 30,000 or less per year? If you are part of a group practice, does the group fall beneath the low-volume threshold ofseeing 100 or fewer Medicare patients OR billing Medicare 30,000 or less per year? Is 2017 your first year billing Medicare Part B using the Physician Fee Schedule? Do you bill for items and services furnished by a MIPS eligible clinician only under a facultybased methodology?If the answer is yes to any of these questions, MIPS does NOT apply to you in 2017. CMS will contactclinicians who participate in Medicare Part B in December 2016 to confirm their eligibility. If you arenot eligible, you may still choose to report voluntarily and receive feedback on your performance. If4

you voluntarily report, you will receive feedback on your performance, but you will not be subject topayment adjustments in 2019.23If MIPS does NOT apply to you, learn as much as you can anyway.Value-based payments are an important goal for all the major payers, not just Medicare. To meetthese demands, all behavioral health organizations will need to cultivate an organizational culturethat embraces change, and develop the infrastructure needed to measure progress, demonstratevalue and improve health outcomes.Educate your team.Successful participation in the Quality Payment Program will depend on everyone on yourteam. Share information with practice administrators, clinicians and support staff. Make surethey understand how CMS will measure performance, and how MIPS may affect Medicarereimbursements starting in 2019.(See http://www.thenationalcouncil.org/macra/ for helpful resources)45Connect with the CMS-funded Transforming Clinical Practice Initiative (TCPI).TCPI supports 29 Practice Transformation Networks and Support and Alignment Networks acrossthe country, which provide free resources and technical support to help practices improve qualityof care, reduce costs, and prepare for value-based payment arrangements. Visit http://www.healthcarecommunities.org/ or contact the National Council to learn more.Stay Up-to-DateCMS released the final rule in October, but has requested comments on certain componentsthat may affect eligible behavioral health care providers. Also, Quality Payment Program reportingrequirements will change over time. The National Council can help you stay informed and supportyou to meet these requirements every year. Subscribe to the National Council’s Capitol Connectorblog and check out our website’s MACRA resources.Quality6If your practice currently participates in PQRS What type of feedback have you received on your prior performance? (If you have not alreadyreceived feedback via your Quality and Resource Use Report (QRUR), refer to CMS guidance here). What can you do to improve your performance? Remember: Unlike PQRS, MIPS is NOT a payfor-reporting mechanism. The data you submit for each quality measure will be compared tobenchmarks in order to determine your Quality score. The baseline period for deriving benchmarkswill be two years prior to the performance year, which will enable CMS to publish measurebenchmarks prior to the start of the relevant performance year. Review the MIPS quality measures, including the Behavioral/Mental Health measure set. Which six5

quality measures would make the most sense for your practice to report on in 2017? (Don’t forgetto identify at least one outcome/high-priority measure).7If your practice does NOT currently participate in PQRS Review the MIPS quality measures, including the Behavioral/Mental Health measure set. Which quality measures would make the most sense for your practice to report on in 2017? Work with your staff to determine how you will incorporate data collection into current workflows. Start collecting data and measuring performance on 1-2 of your chosen measures to start.Determine your baseline so you know how much you will need to improve your performance onceCMS determines performance thresholds for each measure.If your practice does NOT participate in PQRS in 2016, you may receive a negative paymentadjustment in 2018.Cost8Understand your cost of care.If your practice participated in PQRS last year, review your Quality and Resource Use Report (QRUR).This report explains your performance in terms of cost and quality so you can prioritize areas forimprovement. (If you have not received your QRUR, please refer to CMS’s guidance on how to obtainit).Although this category will not count toward your final score in 2017, CMS will still provide feedbackbased on your 2017 performance. The weight of this category will also increase over time, countingfor 30% of your final score by the 2020 performance year.CMS will assess performance in the Cost performance category using measures based onadministrative Medicare claims data. Therefore, MIPS eligible clinicians are not required toindependently report for this category.Advancing Care Information910If you have an EHR, make sure it is certified EHR technology (CEHRT)A well-designed CEHRT can help you fulfill current quality reporting requirements and providereal-time summaries of your progress on quality measures. If you have an EHR, determinewhether it is 2014- or 2015- edition certified—the version will determine which Advancing CareInformation measures you will choose to report in 2017.If you do NOT have an EHR, use a qualified clinical data registry.CMS defines a qualified clinical data registries (QCDR) as an approved entity that collects medicaland/or clinical data for the purpose of patient and disease tracking to improve the quality ofpatient care. They can streamline reporting, help you identify high-risk populations, and maketargeted improvements in clinical practice. CMS approved this list of QCDRs for reporting in2016.6

Improvement Activities11Review the list of MIPS Improvement Activities (see page 18). Which improvement activities do you currently have in place? How many points would theyearn for your practice? Would any of your current improvement activities need to be modified to comply with CMS’sdefinition? If your organization is currently not engaging in any improvement activities, or is not engagingin enough activities to earn a full 40 points, which activities would be the easiest to implement,and make the most sense for your practice?Small practices and those located in rural or Health Professional Shortage Areas will onlyneed to attest to completing two activities in this category to earn full credit.12Subscribe to the BHive and Capitol Connector to stay abreast of upcoming practiceimprovement projects offered by the National Council. Contact Communications@TheNationalCouncil.org to sign up!SECTION 3Quality Performance Category (60%)For the 2017 reporting year, the Quality performance category is worth 60% of the MIPS final score. Anadaptation of the PQRS program, the MIPS Quality category requires clinicians to choose six measures toreport that best reflect their practice. At least one measure must be an outcome or other high-prioritymeasure.Clinicians may report measures from the Mental/Behavioral Health Specialty Set to fulfill this requirement(see Table 1), which includes 25 measures. In 2017, clinicians who do not have enough measures to selectat least six should choose and report on all of the measures that apply to them.Clinicians may earn bonus points in this category for measures gathered and reported electronically viaa qualified clinical data registry, CMS Web Interface (groups of 25 clinicians only) or CEHRT mechanisms.7

Table 1. MACRA Quality Payment Program Behavioral Health Specialty SetQuality issionMethodADHD: Follow-UpCare for isorder (ADHD)MedicationPercentage of children 6-12 yearsof age and newly dispensed amedication for attention-deficit/hyperactivity disorder (ADHD) whohad appropriate follow-up care. Tworates are reported. a. Percentageof children who had one followup visit with a practitioner withprescribing authority during the 30Day Initiation Phase. b. Percentageof children who remained on ADHDmedication for at least 210 daysand who, in addition to the visit inthe Initiation Phase, had at leasttwo additional follow-up visits witha practitioner within 270 days (9months) after the Initiation Phaseended.ProcessNoEHRAdherence toAntipsychoticMedications forIndividuals withSchizophreniaPercentage of individuals atleast 18 years of age as of thebeginning of the measurementperiod with schizophrenia orschizoaffective disorder who hadat least two prescriptions filledfor any antipsychotic medicationand who had a Proportion of DaysCovered (PDC) of at least 0.8 forantipsychotic medications duringthe measurement period (12consecutive months)IntermediateOutcomeYesRegistryAdult MajorDepressiveDisorder (MDD):Coordination ofCare of Patientswith SpecificComorbidConditionsPercentage of medical recordsof patients aged 18 years andolder with a diagnosis of majordepressive disorder (MDD) anda specific diagnosed comorbidcondition (diabetes, coronaryartery disease, ischemic stroke,intracranial hemorrhage, chronickidney disease [stages 4 or 5],End Stage Renal Disease [ESRD]or congestive heart failure) beingtreated by another clinician withcommunication to the cliniciantreating the comorbid conditionProcessYesRegistry8

Anti-DepressantMedicationManagementPercentage of patients 18 years ofage and older who were treatedwith antidepressant medication,had a diagnosis of majordepression, and who remainedon an antidepressant medicationtreatment. Two rates are reported.a. Percentage of patients whoremained on an antidepressantmedication for at least 84 days(12 weeks). b. Percentage ofpatients who remained on anantidepressant medication for atleast 180 days (6 months).ProcessNoEHRCare PlanPercentage of patients aged 65years and older who have anadvance care plan or surrogatedecision maker documented in themedical record or documentation inthe medical record that an advancecare plan was discussed but thepatient did not wish or was not ableto name a surrogate decision makeror provide an advance care planProcessYesClaimsChild andAdolescentMajor DepressiveDisorder (MDD):Suicide RiskAssessmentPercentage of patient visits forthose patients aged 6 through 17years with a diagnosis of majordepressive disorder with anassessment for suicide riskProcessYesEHRClosing theReferral Loop:Receipt ofSpecialist ReportPercentage of patients withreferrals, regardless of age, forwhich the referring providerreceives a report from the providerto whom the patient was referredProcessYesEHRDementia:CounselingRegarding SafetyConcernsPercentage of patients, regardlessof age, with a diagnosis ofdementia or their caregiver(s)who were counseled or referredfor counseling regarding safetyconcerns within a 12 month n &SupportPercentage of patients, regardlessof age, with a diagnosis of dementiawhose caregiver(s) were providedwith education on dementia diseasemanagement and health behaviorchanges AND referred to additionalresources for support within a 12month periodProcessYesRegistryRegistry9

Dementia:CognitiveAssessmentPercentage of patients, regardlessof age, with a diagnosis of dementiafor whom an assessment ofcognition is performed and theresults reviewed at least oncewithin a 12 month periodProcessNoEHRDementia:Functional StatusAssessmentPercentage of patients, regardlessof age, with a diagnosis of dementiafor whom an assessment offunctional status is performed andthe results reviewed at least oncewithin a 12 month periodProcessNoRegistryDementia:Management ofNeuropsychiatricSymptomsPercentage of patients, regardlessof age, with a diagnosis ofdementia who have one or moreneuropsychiatric symptoms whoreceived or were recommendedto receive an intervention forneuropsychiatric symptoms within a12 month mptomAssessmentPercentage of patients, regardlessof age, with a diagnosis of dementiaand for whom an assessment ofneuropsychiatric symptoms isperformed and results reviewed atleast once in a 12 month periodProcessNoRegistryDepressionRemission at SixMonthsAdult patients age 18 years andolder with major depression ordysthymia and an initial PHQ9 score 9 who demonstrateremission at six months definedas a PHQ-9 score less than 5.This measure applies to bothpatients with newly diagnosedand existing depression whosecurrent PHQ-9 score indicates aneed for treatment. This measureadditionally promotes ongoingcontact between the patient andprovider as patients who do nothave a follow-up PHQ-9 score atsix months ( /- 30 days) are alsoincluded in the denominatorOutcomeYesRegistry10

DepressionRemission atTwelve MonthsPatients age 18 and older withmajor depression or dysthymiaand an initial Patient HealthQuestionnaire (PHQ-9) scoregreater than nine who demonstrateremission at twelve months ( /- 30days after an index visit) definedas a PHQ-9 score less than five.This measure applies to bothpatients with newly diagnosed andexisting depression whose currentPHQ-9 score indicates a need fortreatment.OutcomeYesEHRDepressionUtilization of thePHQ-9 ToolPatients age 18 and older withthe diagnosis of major depressionor dysthymia who have a PatientHealth Questionnaire (PHQ-9) tooladministered at least once during a4-month period in which there wasa qualifying visitProcessNoEHRDocumentationof CurrentMedications in theMedical RecordPercentage of visits for patientsaged 18 years and older for whichthe eligible professional atteststo documenting a list of currentmedications using all immediateresources available on the dateof the encounter. This list mustinclude ALL known prescriptions,over-the-counters, herbals,and vitamin/mineral/dietary(nutritional) supplements AND mustcontain the medications’ name,dosage, frequency and route Screen and FollowUp PlanPercentage of patients aged 65years and older with a documentedelder maltreatment screen using anElder Maltreatment Screening toolon the date of encounter AND adocumented follow-up plan on thedate of the positive screen.ProcessCMS WebInterfaceRegistryEHRRegistryYesClaimsRegistry11

Follow-Up AfterHospitalizationfor Mental Illness(FUH)The percentage of

In September 2016, CMS announced that MIPS eligible clinicians will have three reporting options to avoid a negative payment adjustment in 2019: Option 1: Test the Quality Payment Program. As long as you submit some data via MIPS, including data from after Janua

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