MACRA Resource Center

Find the tools and resources you need to help you understand and implement MIPS or APMs

Overview
MIPS explained
APMs
MIPS tools
Practice scenarios
Help and FAQs

Tab 1

What is MACRA? The 2015 Medicare Access and Chip Reauthorization Act (MACRA) repealed the sustainable growth rate formula, or SGR, which had been the basis for determining annual updates to the Medicare fee schedule. MACRA guarantees a positive annual update of 0.5% until 2019 and set goals to move Medicare payment from volume to value. Looking to simply avoid the penalty? Learn how.

Who is eligible to participate? The following professionals who bill Medicare more than $90,000 annually OR provide care for more than 200 Medicare patients per year are eligible to participate:

Physician (including doctor of medicine, doctor of osteopathy, osteopathic practitioner, doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, doctor of optometry, and chiropractor)
Physician assistant
Nurse practitioner
Clinical nurse specialist
Certified registered nurse anesthetist

Who is exempt from 2018 MIPS participation? You are exempt from participation in MIPS if any of the following are true:

You have ≤$90,000 in Medicare Part B allowed charges per year.
You see ≤200 Medicare patients per year.
This is your first year as a Medicare participating provider.
If you qualify for an extreme/uncontrollable circumstance as outlined by CMS.

Determine whether you are eligible to participate by visiting the Quality Payment Program website and entering your NPI.

For all MACRA participants, there are two pathways to choose from: MIPS and APMs. Most dermatologists will participate in MIPS.

Merit-based Incentive Payment System (MIPS) combines existing Medicare reporting requirements into a single entity that ties fee-for-service payment to performance using an overall physician quality score. Beginning in 2019 it will replace payment cuts associated with PQRS, meaningful use, and the value-based modifier with the potential to earn a bonus or incur a penalty depending on your performance score. Learn more about MIPS.

Advanced Alternative Payment Models (APMs) reward physicians who are participating in payment models that attempt to incentivize health care decision-making based on quality, outcomes, and cost savings. Beginning in 2019 until 2024 doctors participating in Advanced APMs will receive a lump sum bonus payment of 5% of their Medicare charges. Learn more about APMs.

Principles of Documentation for Dermatology

Ensure your documentation meets payer regulations and supports the CPT® and ICD-10-CM codes you have reported, and and helps keep quality measures score intact.

Coding Ultimate Pack

Get the entire collection of AADA and AMA coding resources in one convenient pack. You’ll receive the latest CPT® and ICD-10-CM codes and guidelines.

Coding Value Pack

Every dermatology practice needs these three must-have AADA and AMA coding resources to accurately code and submit claims in 2019.

Coding Deluxe Pack

Four essential AADA and AMA manuals plus our popular 2019 Coding & Practice Updates for 2019 Live Webinar. Everything your practice needs for CPT® and ICD-10-CM updates for 2019 in order to document correctly and support your claims.

2019 Coding Webinar All-Access Pass

Stay up-to-date on the latest 2019 coding and billing practices! Get unlimited access to seven webinars at one great price.

Need help? Call the Academy's practice support line. Speak one-on-one with an Academy expert who will help you navigate your practice issues. Complimentary for a limited time. Call 866-503-SKIN, option 1.

Tab 2

MIPS will be the most likely pathway for dermatologists to participate in MACRA. Beginning in 2019, physicians will have the potential to earn a bonus or incur a penalty based on an overall MIPS performance score.

Download a PDF with all of your reporting options for both large and small practices.

Avoiding a penalty

To only avoid the penalty (for practices of <16 providers) you must score at least 15 points. Report ONE of the following for any time period:

Five quality measures at least one time each*
One high-weighted improvement activity
Five required measures making up the base score of the promoting interoperability (PI) category PLUS integration with DataDerm

*The AAD strongly recommends practices report more than one time as an insurance policy in the event of submission issues or inaccuracies. Failure to correctly report in 2018 will result in a 5% penalty in 2020.

This video from the February 2018 issue
of Dermatology World explains how to avoid
a 5% penalty and qualify for bonuses.

Getting a small incentive (less than 0.5%)

To get a small incentive (for practices with <16 providers), you must score between 15 and 70 points. Report ONE of the following:

At least two quality measures on all of your eligible patients (for the full year)
Five required measures making up the base score of the promoting interoperability (PI) category PLUS integration with DataDerm PLUS at least one performance measure (for at least 90 days)
Two quality measures at least one time each AND one high-weighted improvement activity (for at least 90 days)
Five required measures making up the base score of the promoting interoperability category PLUS integration with DataDerm AND one high-weighted improvement activity (for at least 90 days)

Getting the maximum incentive (5%)

To get the maximum incentive (for practices with <16 providers), you must score over 70 points. Report ALL of the following for the full year:

Six quality measures on all of your eligible patients
One high-weighted improvement activity
Five required measures making up the base score of the promoting interoperability (PI) category.

If you do not have an EHR, you are still eligible for the maximum incentive. You first must apply for a hardship exemption and get approval, and then your quality score will be re-weighted to 75 points.

Please note there are additional requirements for practices with more than 15 providers. Contact AAD PMC Staff for questions at MACRA@aad.org.

MIPS metrics

To calculate your MIPS score, CMS will evaluate your performance in four core areas that will be weighted. CMS has indicated the weights below for 2018, but these will adjust as the program evolves. The minimum performance threshold is 15 points to avoid the 5% penalty. To receive an incentive of 5%, you must score 70 points or more. Note: this information is for practices of 15 or fewer. providers. Please contact staff at MACRA@aad.org for information about practices of 16 or more providers.

Core areas	Quality reporting	Promoting interoperability (PI)	Improvement activities (IA)	Cost
Description	Clinicians choose quality measures to report to CMS that best reflect their practice. Learn more about quality scoring.	This category assigns credit for use of a certified EHR and reporting of EHR-specific measures. Learn more about PI scoring.	This category is rewards innovation and improvement activities that center around things such as care coordination, engaging beneficiaries, patient safety, expanding patient access, and population management. Learn more about IA scoring.	The Cost category is new for 2018 and will be assessed from your Medicare Spending per Beneficiary (MSPB).
Max points	50 points	155 points possible, but capped at 100 points	20 points	10 points
Category weight	50% of overall MIPS score	25% of overall MIPS score	15% of overall MIPS score	10% of overall MIPS score
Former program	Physician Quality Reporting System (PQRS)	EHR Incentive Program (meaningful use)	New category	Value-based modifier
Performance period	1 year (365 days) / starting Jan. 1- Dec. 31, 2018	90-day minimum between Jan. 1-Oct. 2, 2018	90-day minimum between Jan. 1-Oct. 2, 2018	1 year (365 days) / starting Jan. 1-Dec. 31, 2018.
Reporting method(s)	Individual Registry (such as DataDerm) EHR Claims (only small subset of measures)	Individual Registry (such as DataDerm) EHR Attestation via CMS portal	Individual Registry (such as DataDerm) EHR Attestation via CMS portal	CMS will calculate score based on claims data. No action needed by providers.
Reporting method(s)	Group Registry (such as DataDerm) EHR CMS web interface (groups of >25 eligible clinicians) Claims (only small subset of measures)	Group Registry (such as DataDerm) EHR CMS web interface (groups of >25 eligible clinicians) Attestation via CMS portal	Group Registry (such as DataDerm) EHR CMS web interface (groups of >25 eligible clinicians) Attestation via CMS portal
Requirements	Case minimum: quality measures must meet the 20-case min for incentive Data completeness: Measures must contain at least 60% of all EC patients across ALL payers for incentive	2014 or 2015 certified EHR Base score minimum: Must perform base score measures on at least one patient to quality for additional points in this category	Groups with <16 providers may attest to 2 medium-weighted IA for 90 days (minimum) or 1 high-weighted IA for full credit	Clinicians will receive a score for their performance. No additional data submission is required.
Scoring	10 points possible per measure 3 points per measure for submitting data for practices ≤ 15 providers Topped out measures only earn 7 points maximum Earn more points depending on benchmarks	Base score (50 pts max required) Performance score (90 pts max available) Bonus score (15 pts max available)	10 points per medium-weighted activity 20 points per high-weighted activity 20 points max possible	CMS will calculate based on claims data. No action needed by providers.
Final score calculation	(Total points earned on 6 measures) + (Bonus points) / Total points possible (50)	(Base + Performance + Bonus scores) / Total points possible (capped at 100)	Total points earned / Total points possible (20)
Additional information	5 bonus points for small practices (<16 providers) 2 bonus points for each additional outcome measure 1 bonus point for each additional high-priority measure 1 bonus point for each measure submitted via EHR integration w/DataDerm	10 bonus points for EHR integration with DataDerm	If you report as a group, only one member of the group has to meet this category for the group to receive full credit.	Review your historical QRUR report to get a better idea of what your score may be.

Tab 3

5.APMs.png Advanced APMs will initially be the pathway less traveled by dermatologists and will be most accessible to those practicing in large academic centers or large multi-specialty group settings. To qualify you must meet benchmarks for the amount of payment you receive through an Advanced APM or the number of patients in an Advanced APM that you care for. Learn more about APMs on the Quality Payment Program website.

Those who do successfully participate in this pathway will receive a 5% bonus payment from 2019-2024 and will be eligible for larger fee schedule updates beginning in 2026.

Not all APMs will be deemed Advanced APMs, and not all who participate in Advanced APMs will qualify for the bonus payment. To receive the 5% bonus payment in 2019, qualified clinicians must have at least 25% of their Medicare Part B Payments or 20% of their Medicare patient population flow through the Advanced APM.

Advanced APMs must meet the following requirements:

Be CMS Innovation Center models, Shared Savings Program tracks, or certain federal demonstration programs
Require participants to use certified EHR technology
Base payments for services on quality measures comparable to those in MIPS
Be a Medical Home Model expanded under Innovation Center authority or require participants to bear more than nominal financial risk for losses.

View a list of approved APMs.

Those who participate in an Advanced APM but do not qualify for the 5% bonus payment may still be able to forego MIPS participation; however, many clinicians will participate in both APMs and MIPS. In 2017, clinicians participating in APMs and MIPS at the least will receive full credit in the improvement activities category.

Tab 4

The Academy developed a series of MIPS tools and resources to help answer questions and guide you through the Quality Payment Program (QPP). Not sure where to begin? Try the tools in the order listed below.

1. MACRA readiness checklist

Download this checklist to help you begin to prepare your practice for CMS' Quality Payment Program.
Download checklist

2. MIPS financial assessment tool

Enter your 2016 Medicare Part B reimbursements and receive an estimate of your potential maximum penalty and incentive for the 2018 reporting year.
Access tool

3. MIPS reporting: Decision support tool

This tool will help you determine how to participate in MIPS for 2018. Answer questions about how much reporting you are willing or able to do, and the tool will present you with your options, including specifics about what and how much you need to report.
Access tool

4. Quality measures selection tool

This tool will help your practice find eligible measures based on how you report, whether via paper, EHR, or DataDerm. You will also to be able to access detailed measures information such as reporting tips, the measure specification, and more.
Find measures

5. MACRA community

Join an online discussion forum that allows members to ask staff experts questions about MACRA.
Ask an expert

Get all your 2018 reporting options in one place!


Download for practices with 15 or fewer providers				Download for practices with more than 16 providers

Tab 5

Solo practitioner (no EHR) looking to avoid a MIPS penalty

Dr. Smith is the owner and sole care provider at Smith Dermatology in Miami, where he has been in private practice for 28 years. Dr. Smith practices general dermatology, with some cosmetics. About 25% of his patients are covered by Medicare, and he receives about $330,000 in reimbursements annually from Medicare Part B.

Five years ago, he researched the cost to purchase and implement an EHR system — about $45,000. At the time, he decided that neither bonus nor penalties were enough to tackle such a costly and time-consuming project, especially considering his limited staff to help with the transition. Dr. Smith does not plan to retire in the next five to six years, although he will make a decision after learning more about future penalties incurred from not using an EHR.

Dr. Smith did, however, enroll in DataDerm, the AAD’s clinical data registry. Enrollment was easy, and with Medicare reimbursements on the precipice of major change, he wanted access to a platform that would give him the option to report in 2017 and beyond, without the high cost of EHR implementation. With insurance networks scrutinizing costs and terminating him from networks, he hoped that a dermatology-specific registry would help him prove his value to payers and policymakers.

In 2017, Smith decided to avoid the penalty for failing to report under the first year of the MIPS program. To do so, he reported the Biopsy Follow-Up quality measure on 50 percent of his applicable patients for 90 days. Reporting through DataDerm was easier than Smith had expected. However, he knows that the minimum threshold for participation has been raised for 2018. To continue to avoid the penalty, he will have to report five quality measures at least one time each.

WEIGHING THE OPTIONS

Dr. Smith must decide whether the cost of reporting five measures is worth avoiding the MIPS non-participation penalty. With reporting requirements multiplying, he is also wondering if he should rethink his decision not to adopt an EHR.

To make his decision, he calculates the total cost and potential ROI of his options.

Option 1: Opting out of continuing participation in MIPS

5% penalty for non-participation in 2018¹ = $16,500
9% penalty for non-participation in 2020 = $29,700

Cumulative penalty costs: 2018-2020 = $69,300

Option 2: Continuing minimal MIPS participation

Avoid 5% payment penalty by reporting five quality measures at least one time*. View measures.²

Reporting costs:
Submit quality measure through DataDerm = $295/year
Physician’s time for data registry reporting (~7 hours/year) = $1,750
Total cost in 2018: $295 + $1,750 = $2,045
Cumulative cost by 2020: $2,045 X 3 (years) = $6,135

*The AAD strongly recommends practices report more than one time in the event of submission issues or inaccuracies. Failure to correctly report in 2018 will result in a 5% penalty in 2020.

¹Payment penalties to be applied two years after reporting year.
²Learn about other options for minimal participation in AAD’s MACRA Resource Center.

THE DECISION

Dr. Smith decides to continue his participation in MIPs, expanding the number of quality measures he reports from one to five. An investment of about $2,000 dollars in 2018 should save him over $16,000 in 2020 payments, for a net payoff of $14,000. MIPS penalties will also continue to rise through the 2020 reporting year. If Dr. Smith can maintain minimal participation over that time for the same reporting criteria, he stands to recoup more than $60,000.

Bonus option: Adopting an EHR

Dr. Smith realizes he may eventually have to adopt an EHR system if he hopes to keep up with multiplying reporting requirements. At $45,000, the cost is considerable. But if done properly, the move could earn him additional MIPS points under the Promoting Interoperability requirement, qualifying Dr. Smith for a modest incentive. A hypothetical 1 percent increase would improve his Medicare reimbursements by about $3,300 per year.

Dermatology solo practice aims for moderate incentive by submitting 2 measures

Dr. Vasquez has been in solo practice in Phoenix, Arizona, for about 10 years. Working in the Valley of the Sun, she sees a high percentage of patients for skin cancer screenings and care. Her practice has grown with the area’s rising retiree population, and she now employs two PAs. Together, they bring in about $631,000 in Medicare part B reimbursements.

At 45 years of age, Dr. Vasquez hopes to remain in practice for many years. She also expects her practice to continue to grow. As such, she realizes that she will eventually need to adopt an EHR system. She has so far managed to comply with minimum reporting requirements for MIPS, but the requirements are quickly multiplying. Dr. Vasquez knows that an EHR system will make it much easier to fulfill reporting requirements, helping her to avoid substantial penalties and perhaps even earn an increase in reimbursements. But she wants to make sure that the initial outlay of $42,000 to adopt an EHR system is a sound business investment.

To avoid a penalty for not participating in MIPS, Dr. Vasquez knows that she will have to submit five quality measures at least one time each during 2018¹. She also knows that she can report two quality measures not topped out an all eligible patients for the full year to qualify for an increase in reimbursement. Dr. Vasquez plans to submit the measures through DataDerm, the AAD’s clinical data registry. She estimates that it will take 7 hours of staff time per practitioner to report five measures one time, for a total cost of approximately $3,500. To report two measures for the full year, qualifying for a modest incentive, will take about 10 hours per practitioner, for a cost of approximately $5,000.

WEIGHING THE OPTIONS

Looking at her MIPS options for 2018, Vasquez rules out going for a maximum incentive, deciding that conducting such extensive reporting while adopting a new EHR system would be too much of a burden. That leaves three scenarios to consider: (1) non-participation, (2) submitting five quality measures at least one time each to avoid penalty, or (3) submitting two measures for the entire year in the hopes of receiving a modest increase in reimbursements.

Dr. Vasquez calculates the total cost and potential ROI for each option using the AAD’s financial assessment tool.

Option 1: No MIPS participation with payment penalty

5% penalty for non-participation in 2018 = $31,550
9% penalty for non-participation in 2020 = $56,790

Cumulative penalty costs for not participating from 2018 to 2020: $132,460

Option 2: Minimal MIPS participation with EHR adoption

EHR adoption: $42,000
EHR upgrade fees per year: $1500
Submitting quality measure through DataDerm: $885 ($295 each for one derm and two PAs)
Staff time for reporting through EHR/DataDerm: $3,380.64 ($1,126.88 each for one derm and two PAs)

Total cost in 2017: $47,765.64

Option 3: Cost/Benefit of reporting two measures over entire year

Additional staff time: $1,500
Hypothetical increase of 1% earned in 2018: $6,310²

THE DECISION

Dr. Vasquez decides to adopt the EHR system and to report two non-topped out measures for the full year for a potential modest incentive. The decision to adopt the EHR system is straightforward: Avoiding the MIPS penalty for the next two years will more than pay for the cost of adopting the new system. With the system in place, her office can easily avoid the penalty and have the opportunity to participate in future options under the MIPS program.

The decision to go for a modest incentive is a bit of a gamble since there is no way of knowing what the exact payoff will be. An increase of 1% may be a bit hopeful, but even an increase of 0.25% would offset the extra staff time required, for an even break. Dr. Vasquez decides to take the risk; she may not only earn a little extra if her scores meet the incentive range, the experiment will be relatively low-risk, and the results may help inform her future decision-making.

1. The AAD strongly recommends practices report more than one time in the event of submission issues or inaccuracies. Failure to correctly report in 2018 will result in a 5% penalty in 2020.
2. Actual increase based on comparison of measure score against benchmarks. 1% incentive may not be achievable and will not be known until CMS calculates all submission scores in 2020.

Dermatologists in multispecialty setting, not eligible for APM track

Dr. Gupta is one of eight dermatologists in Quality Physicians Group, a multispecialty practice in Kansas City, Missouri. The group employs 80 primary care providers and 65 specialists spread over dozens of medical specialties. Quality Physicians Group gets fewer than 25% of its patients and payments through an alternative payment model (APM), and thus does not qualify for an APM-track incentive. Medicare Part B reimbursements form an important part of the group’s business, and the group’s executive committee, mindful of the need to grow revenues, votes for full participation in the MIPS program in the 2018 reporting year.

On hearing the news, Dr. Gupta takes a moment to consider his obligations. His services bring in about $300,000 dollars in Medicare Part B reimbursements, so he knows that his cooperation will be important to the group’s MIPS effort. Having previously participated in the PQRS and MU programs (now combined into the MIPS program) and the first year of MIPS with Quality Physicians, Dr. Gupta knows that the group will cover any EHR and reporting costs associated with MIPS. He also knows that under the terms of his compensation agreement, he is eligible for a bonus equal to 2% of any additional revenue generated across the dermatology section for participation in the MIPS program.

WEIGHING THE OPTIONS

Quality Physicians Group already supplies its practitioners with an EHR and will cover any fees and/or other overhead associated with reporting. This leaves Dr. Gupta to consider his potential bonus. The dermatology section includes eight physicians, two PAs and two NPs. Together, they bring in an estimated 3 million in Medicare part B reimbursements.

Potential 5% incentive for the dermatology section under MIPS for 2018: $150,000
Dr. Gupta’s 2% bonus: $3,000

Cumulative potential incentive for dermatology section by 2020: $523,345
Cumulative 2% bonus over four years: $10,466.90

MOVING FORWARD

Dr. Gupta is excited at the opportunity to earn a sizeable bonus. And, since he is already using an EHR and has participated in PQRS, MU, and the 2017 reporting year of MIPS, he is undaunted by the requirements of reporting. He realizes, however, that he will need to be as informed as possible to get the most out of his participation. In the lead-up to full MIPS participation, he makes a list of questions that will need to be answered. For example, he wants to know if he will be expected to participate in any practice improvement activities and whether, as a member of a multispecialty practice, he will be required to report any non-dermatology specific quality measures.

Group practice aims for maximum incentive

Dr. Lee and Dr. Baker are the owning partners of Dermatology Associates of Las Vegas, a thriving group practice in a growing city of some 600,000 people. Their office includes eight dermatologists—Lee, Baker, and six associates—supported by four PAs and four NPs. Together, the sixteen practitioners earn about $4,010,000 a year in Medicare part B reimbursements.

The Dermatology Associates of Las Vegas are old hands when it comes to reporting requirements. They participated in the PQRS and MU programs. In 2017, with the start of the MIPS program, they adopted an EHR system at a cost of $100,000. It was a considerable effort and expense, but it helped them to earn a modest incentive that first reporting year.

Encouraged by this success, Baker and Lee meet to weigh their many options for the 2018 reporting year. They quickly identify two options: Continued moderate participation in MIPS to achieve a minimal incentive, or full participation to qualify for a maximum incentive.

WEIGHING THE OPTIONS

After conducting some additional research, Lee and Baker reconvene to crunch the numbers. They decide to calculate ROI’s for two scenarios. The good news is that with $2,500 yearly upgrades, their newly adopted EHR fulfills the five required measures of the Promoting Interoperability (PI) category. The EHR is also integrated with DataDerm. With all that going for them, they need report only two quality measures (that are not topped out) to qualify them for a moderate incentive.

To qualify for the maximum incentive, they would need to submit six quality measures on all eligible patients and two high-weighted improvement activities, in addition to meeting the Promoting Interoperability requirements. For purposes of comparison, they also calculate the cost of non-participation.

Non-participation

5% penalty for non-participation in 2018: $200,500
9% penalty for non-participation in 2020: $360,000
Cumulative penalty costs for not participating from 2018 to 2020: $841,200

Option 1: Moderate participation

EHR upgrade fees per year (fulfilling PI requirements): $2,500
Submitting quality measures through DataDerm: $4,720 ($295 each for eight derms and eight NPCs)
Staff time for reporting two quality measures through EHR/DataDerm: $18,029.92 ($1,126.87 [seven hours of staff time] for each of 16 practitioners)
Total cost in 2018: $25,249.92
Total cost by 2020: $75,749.75
Hypothetical 1% incentive for 2018: $40,100¹
Cumulative 1% incentive over three years: 242,208.01¹

Option 2: Full participation

EHR upgrades per year (fulfilling PI requirements): $2,500
Submitting quality measures through DataDerm: $4,720 ($295 each for eight derms and eight NPC’s)
Staff time for reporting six quality measures through EHR/DataDerm and fulfilling two high-weighted practice improvement activities: $38,635.38 ($2,414.73 [15 hours staff time] for each of 16 practitioners)

Total cost in 2018: $45,855.38
Total cost by 2020: $137,566.14
Maximum incentive for 2018: $200,500¹
Cumulative maximum incentive by 2020: $1,596,441.15¹

¹Actual increase will be based on comparison of measure score against benchmarks. One percent incentive may not be achievable and will not be known until CMS calculates all submission scores in 2020.

THE DECISION

After some back and forth, Baker and Lee agree that Dermatology Associates of Las Vegas should embrace full participation in MIPS in the hopes of getting a large incentive. Moderate participation appears to offer a slight gain in profits. But full participation should provide an even greater payoff and put Dermatology Associates of Las Vegas on track to grow profits even further over the next several years.

Though there is no guarantee that the practice will receive the maximum incentive possible, it should break even at around one-fifth of the cumulative incentive for which it qualifies.

Tab 6

Need help? Call the Academy's practice support line

Speak one-on-one with an Academy expert who will help you navigate your practice issues. A complimentary member benefit for a limited time.

Call 866-503-SKIN, option 1.

Additional help options:

Download a PDF with 2018 reporting options for both large and small practices.
Download CMS' Technical Assistance Resource Guide for further help.

MACRA FAQs

MACRA glossary

APM = (Advanced) Alternative Payment Model. A payment approach that gives additional incentive payments to professionals under ACO models, or those that bear more than the nominal amount of financial risk. Most dermatologists will not be eligible for this track.There are two types of APMs under MACRA: Advanced APMs, which exempt participating providers from MIPS and offer a 5% payment bonus, and MIPS APMs, which require some MIPS participation, but may result in a bonus payment from certain components of the MIPS performance score.

EP or EC = Eligible Professional / Eligible Clinician. Health professionals who are required to participate in either MIPS or an APM. Physicians (MD or DO), nurse practitioners (NP), physician assistants (PA), clinical nurse specialists, certified registered nurse anesthetists, and groups who bill under Medicare Part B.

MACRA = The Medicare Access and CHIP Reauthorization Act of 2015. MACRA is the 2015 law that replaced the flawed "SGR" or sustainable growth rate. It creates the new incentive/penalty structure for Medicare Part B reimbursement beginning with 2017 payment. MACRA has two tracks: MIPS or Advanced APMs.

MIPS = The Merit-Based Incentive Payment System. One of the two pathways to take under the MACRA rule. Most dermatologists will be on the MIPS pathway. Providers earn positive or negative payment adjustments based on data submitted to CMS.

QCDR = Qualified Clinical Data Registry. A CMS-approved reporting mechanism that collects medical/clinical data for the purpose of quality reporting to federal pay-for-reporting programs. While originally created for PQRS, they are now used to support the MACRA Quality Payment Program. The data in QCDRS can cover quality measures across multiple payers and is not limited to Medicare beneficiaries. They also include the ability to report non-MIPS (specialty-specific) measures. Learn more about the AAD's QCDR, DataDerm.

QPP = Quality Payment Program. What CMS is calling the implementation of MACRA.

QR = Qualified Registry. A CMS-approved reporting mechanism that collects medical/clinical data for the purpose of reporting MIPS quality measures. QRs do not support non-MIPS measures. QRs may not offer specialists enough relevant measures to choose from, and may not be best for long-term participation in the QPP.

Am I exempt in 2018?

You are exempt from 2018 reporting and will not receive a penalty or incentive for 2020 if you meet either of the following criteria:

You receive less than $90,000 in Medicare Part B reimbursement per year OR
You see fewer than 200 Medicare Part B patients per year

What are the performance categories?

In 2018 the MIPS score will be factored by four performance areas:

Quality (50%)

Replaces PQRS
Report through DataDerm, EHR, or claims
22 dermatology-specific measures available in DataDerm
Non-dermatology quality measures can be reported via claims

Improvement activities (15%)

Small practices (15 or fewer providers) can report on 1 high-weighted or 2 medium-weighted activities for full credit
Report though DataDerm or EHR

Promoting interoperability (25%)

Replaces EHR meaningful use and advancing care information (ACI)
Can use 2014 or 2015 CEHRT
Flexible scoring
Report through DataDerm

Cost (10%)

New for 2018
Will increase to 30% of total score by 2021
Based on total cost of care for attributed beneficiaries

Do I have to participate in MACRA?

Use the CMS tool to determine whether you need to comply with MACRA this year.

If you are not exempt from MACRA, but choose to not participate, you will receive an automatic 5% penalty from your Medicare Part B reimbursement in 2020. Penalties increase each subsequent year until they max out at 9% for 2022 and beyond.

You are exempt from penalties and the program if you meet one of the following:

Reimbursed from Medicare Part B less than $90,000 per year
See fewer than 200 Medicare Part B unique patients per year

How do I get started with MIPS?

Determine whether you will report via DataDerm, claims, or EHR. Keep in mind that you cannot report dermatology-specific measures via claims.
Determine whether you will be reporting only one measure to avoid the penalty or more to obtain an incentive (See "MIPS explained" tab for more detailed information).
Determine which quality measures and practice improvement activities are relevant to your practice, depending on how many measures you decide to report.

How do I avoid the penalty?

To only avoid the penalty, with no possibility of incentive, (for practices of 15 providers or fewer) you must score at least 15 points.

Report ONE of the following for any time period:

Five quality measures at least
one time each*
One high-weighted improvement activity
Five required measures making up the base score of the promoting interoperability (PI) category PLUS integration with a QCDR like DataDerm

How do I earn a small incentive?

To get a small incentive (less than 0.5%), you must score between 15 and 70 points (for practices of 15 providers or fewer). You will receive this incentive in 2020.

Report ONE of the following for 90 days:

At least two quality measures on all of your eligible patients
Five required measures making up the base score of the promoting interoperability (PI) category PLUS integration with DataDerm PLUS at least one performance measure
One of the above PLUS one high-weighted improvement activity

What are the minimum requirements to avoid the penalty?

Once you've determined that you do indeed need to submit data for MIPS in 2018, you need to submit ONE of the following by December 31, 2018, to avoid the 5% penalty in 2020 (for practices of 15 providers or fewer):

Five quality measures at least one time each*
One high-weighted improvement activity
Five required measures making up the base score of the promoting interoperability category PLUS integration with DataDerm

The AAD strongly recommends reporting on at least 20 patients as an insurance policy in the event of submission issues or inaccuracies. Failure to correctly report will result in a 5% penalty in 2020.

Do I need an EHR to participate in MACRA?

No, you are not required to have an EHR to participate in MACRA in 2018. In fact, you can avoid the penalty and obtain a small incentive even if you are on paper. Paper users can use the Academy's clinical data registry, DataDerm, to submit quality measures or practice improvement activities.

However, paper users can only participate in the quality and practice improvement activities categories within MACRA. The promoting interoperability (PI) category requires an EHR. If you are in a practice with fewer than 15 providers you can apply for a hardship exemption from CMS and have your PI score re-weighted to zero.

Join AAD's MACRA community

The Academy has launched an online discussion forum that allows members to ask staff experts questions about MACRA. AAD members also are encouraged to share their experiences and knowledge with their colleagues.

join the discussion

Note: If you are already logged into aad.org, join the MACRA community now, or learn more about how to use the community.