Healthmonix Advisor

How to Report MIPS in 90 Days

Posted by Christina Zink on September 15, 2017
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To prosper in an industry challenged by constantly changing reform and increasing competition, healthcare organizations must continually increase their quality of care and become more efficient. Reporting MIPS in 2017 is a low-risk, high reward condition to stress-test your clinical workflows for optimized value-based program reporting.


day1.pngLearn about the eligibility of  clinicians in your practice.

The first step to reporting is getting a solid understanding of who in your organization needs to report, and what MIPS categories they will need to report. CMS has made this process easier this year by providing a lookup tool on the Quality Payment Program website. However, this tool is not guaranteed to be fully up-to-date, particularly if you qualified for the low-volume threshold during the second determination period or if a provider is newly enrolled in Medicare. If you are not considered an eligible clinician, it is a good idea to double check the regulations or check back at the end of the year.

RELATED: Three Ways to Check Your MIPS Participation Status

Beyond the eligibility for MIPS as a program, clinicians and groups can be exempt from individual categories in MIPS. If a clinician is hospital-based, doesn't have face-to-face patient visits, is not a physician, or faces a qualifying hardship, they are exempt from the ACI performance category. The 25% of the final MIPS score that would normally be attributed to ACI would be reassigned to Quality, making Quality worth 85% of the final MIPS score for ACI-exempt clinicians. Certified Patient Centered Medical Homes will automatically receive full credit for the Improvement Activities performance category nullifying the need for any further attention to selecting and reporting activities.

day7.pngSelect measures, activities,  and your performance period.

Review measures and activities for quality actions that you've already implemented in your practice, utilizing resources designed for your specialty to narrow down the possibilities. Examine which performance period would best reflect your organization in reference to these measures, and select a window of between 90 days and a year in which to focus your reporting.

RELATED: A Guide to Reporting Quality Measures

Each category has different specifications for complete reporting:

Improvement Activities - Activities are worth either 10 points (medium-weight) and 20 points (high-weight). In total, most eligible clinicians and groups need to report 40 points worth of activities. 

Advancing Care Information - There are four or five base measures that must be reported, but the remaining measures can be selected to try to maximize your ACI category score.

Quality -  Clinicians and groups select six measures, one of which is an outcome measure. If an applicable outcome measure cannot be selected, a high-priority measure may be used in its place.

day15.pngDefine process to report quality measures.

Entering quality measure performance data is often the lengthiest part of the submission process. Time can be saved on data input by investing in a data integration option, allowing for quick uploading of patient-level information. 

day20.pngBegin to input performance category data.

Improvement Activities - In case of audit, ensure that you have documented the activities attested to were performed.

Advancing Care Information - Attesting to the ACI base measures is mandatory. Additionally, if you wish to optimize your score, you should ensure you are providing numerator and denominator information that indicates good performance.

Quality -  Your performance on quality measures will be compared to peer benchmarks from prior performance period. Utilize the MIPSPRO quality benchmark tool to make sure your selected quality measures will result in a good category score. To receive more than the minimum score for a quality measure, you will have to have at least 20 eligible patients.

day50.pngOptimize workflow and complete data entry.

Review your performance and look for gaps that can be quickly addressed. This is also a good time to revisit the measures and performance period you selected if your score is poor. Often times better performance can be achieved by a simple adjustment like adding a field to an intake form or changing a documentation procedure.

day80.pngReview finalized data and prepare for submission.

Prior to submission, you will have to decide whether you would like to submit to CMS on the NPI level or on the TIN level. Once you've reached the data completeness threshold, and you are satisfied with your performance, you can submit.


Congratulations! You are now finished with your MIPS reporting for 2017. If your MIPS final score was 70 or more, you can look forward to an incentive of 4% or more in 2019. If you received less than 70 points, you can still anticipate receiving some incentive if you achieved a score of four or more and participated in more than one performance category. The bare minimum of successful reporting in 2017 is 3 points, in which case you've simply avoided the penalty.

This guide is also available for download in a condensed, one-page sheet for quick reference. To stay informed about the latest MIPS news (including a forthcoming summary of the 2018 MIPS final rule), subscribe to the Healthmonix Advisor.

Topics: MACRA & MIPS, Policy