Published 9/1/2017
Stephen Mason McCollam, MD; Neha Agrawal, MPH

Complying with the Quality Component of MIPS in 2017

The Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP) implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation, passed in April 2015. As a reminder, the MACRA legislation accomplished the following:

  • ended the use of the flawed sustainable growth rate formula for Medicare reimbursement to physicians
  • advanced the policy goal of paying physicians for value versus volume
  • combined Medicare's existing quality reporting programs into one new system

Under the QPP, eligible providers, including orthopaedic surgeons, may choose from two tracks—the Advanced Alternative Payment Models (A-APMs) and the Merit-based Incentive Payment System (MIPS). Most orthopaedic surgeons are expected to initially participate in the QPP via the MIPS path. Those in their first year of enrollment as a Medicare provider during the performance period and those who care for 100 or fewer Medicare beneficiaries or have $30,000 or less in Medicare Part B allowed charges in a year are not required to participate in MIPS.

MIPS combines and replaces three separate Medicare quality-related programs with a single system. MIPS has the following four components:

  • Quality (replaces the Physician Quality Reporting System, or PQRS)
  • Cost (replaces the Value-Based Modifier)
  • Advancing Care Information (ACI, which modifies and replaces the electronic health record [EHR] program)
  • Improvement Activities (a new category)

More information on each MIPS component can be found on the CMS website. This article focuses on how orthopaedic surgeons can comply with the Quality component of MIPS in 2017.

Understanding the MIPS Quality component
Each of the four components of MIPS has a different weight associated with it for the 2017 performance year. The Quality component accounts for 60 percent of a physician's overall MIPS score. Payment adjustments for performance in calendar year 2017 will be made in calendar year 2019.

Specifically, orthopaedic surgeons will see a positive, neutral, or negative adjustment of up to 4 percent in their Medicare payments in 2019, based on their performance during this year (2017). Positive adjustments are based on performance and not just the act of reporting quality data, as was the case with PQRS. CMS will give physicians 3 to 10 points on each quality measure reported, based on their performance against benchmarks.

To potentially earn the full 60 percent of the Quality score, orthopaedic surgeons are required to report on six performance measures from a list of approximately 300 available MIPS measures. Alternatively, orthopaedic surgeons can identify an appropriate Qualified Clinical Data Registry (QCDR) and report on non-MIPS measures. One of these measures must be an outcome measure; if no applicable outcome measures are available, the orthopaedic surgeon must report on at least one high-priority measure. (CMS defines a high-priority measure as an outcome, appropriate use, patient experience, patient safety, efficiency, or care coordination measure.) Bonus points are available for reporting additional outcome and high-priority measures, as well as for end-to-end electronic reporting using certified EHR technology.

As with the previous PQRS program, orthopaedic surgeons can continue reporting individually or as a group, using one of the following:

  • a QCDR
  • a qualified registry
  • EHR vendors
  • administrative claims (no submission required)
  • the CMS Web Interface (only available to groups with 25 or more eligible clinicians)
  • the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey (only available to groups with 2 or more eligible clinicians)

The deadline to submit quality data to CMS is March 31, 2018. Orthopaedic surgeons should select measures that are within the scope of their practice and are already part of their existing workflow. It is likely that most orthopaedic surgeons are already doing what is detailed in a measure; the difference now is that these actions must be documented and reported to CMS. Automated reporting through an electronic medical record is the least burdensome way to report measures to CMS.

2017 Orthopaedic Preferred Specialty (OPS) List
The AAOS Performance Measures Committee evaluated the 2017 MIPS-Quality list of available measures to determine which ones could be used by a majority of orthopaedic surgeons to satisfy the Quality reporting requirements (Table 1). The 2017 Orthopaedic Preferred Specialty Measure Set (OPS List) provides a concise list of available MIPS-Quality measures most relevant to orthopaedic surgeons. It is separate from the 21-measure CMS specialty measure set for orthopaedic surgery. Earlier this year, the AAOS recommended that CMS include the 2017 OPS List in its 2018 specialty measure set for orthopaedic surgery.

This list is designed to be a guide to assist orthopaedic surgeons in choosing measures applicable to their practices. They are not required measures, but rather suggestions for orthopaedic surgeons. The AAOS recommends that members familiarize themselves with the measure titles, descriptions, and available reporting methods for each to help determine the best reporting path.

Of the 30 performance measures on the 2017 OPS List, 1 is an outcome measure and 19 are high priority measures. In addition, 24 of the 30 performance measures on the 2017 OPS List were part of the 2016 PQRS OPS List. (For more information on the 2016 PQRS OPS list, see "Performance Measures Update: Orthopaedic Preferred Measure Set," AAOS Now, July 2016). This list of 30 measures was determined to be either the most relevant or least burdensome for orthopaedic surgeons to report.

Recommended next steps

  • Check qpp.cms.gov to find out if you are required to participate in MIPS.
  • Assess the size and type of your practice, the resources available, the availability of a Qualified Registry, and the conditions seen.
  • Familiarize yourself with the 2017 OPS list and determine which measures are most applicable to your practice. Choose measures that are under your control, align with the clinical conditions you treat, align with your practice improvement goals, and overlap with quality data you may submit to other payers.
  • If you plan to report data via your EHR vendor or a Qualified Registry, contact them directly to verify their reporting deadlines and confirm that they will be able to report your data to CMS.
  • Report on at least six measures, with as many outcome and high-priority measures as possible, to earn bonus points. If you report more than six measures, CMS will apply the top performing measures to your score.
  • Report for a time period that will result in reliable data or that will meet the minimum of 20 patient cases. Reporting for a longer period of time will enable you to track and improve your performance on the measure and will likely increase measure validity and reliability.
  • Review your current billing codes and previous PQRS Feedback Reports. Understanding your PQRS measure reporting and past performance rates will help you determine your best strategy for the MIPS-Quality component.
  • Submit your data by March 2018 to avoid a negative payment adjustment.

Stephen Mason McCollam, MD, is a member of the AAOS Performance Measures Committee and chair of the American Society for Surgery of the Hand Quality Metrics Committee.

Neha Agrawal is an AAOS clinical quality & performance measures specialist who can be reached at agrawal@aaos.org.

Editor's Note: Information about the Quality Payment Program and the Merit-based Incentive Payment System is subject to change as the rulemaking process proceeds. For the most current information, visit the Quality Payment Program website (qpp.cms.gov).