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 The 2015 Medicare Access and Chip Reauthorization Act (MACRA) repealed the sustainable growth rate formula, or SGR, which had been the basis for determining annual updates to the Medicare fee schedule.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.

Be MACRA Ready Webinar

Are you MACRA ready? Join the AAD Expert Physicians to learn how the MACRA final rule impacts you.

AAD-AMA Coding Packs

Rely on the AAD for the most authoritative coding resources for dermatologists. Packages include AAD's new Principles of Documentation for Dermatology.

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.

MIPS and its Impact on Coding & Documentation Webinar

Join the AADA Coding Experts and learn how MIPS and coding updates for 2018 directly impact you.

2018 Coding Webinar All-Access Pass

Stay up-to-date on the latest 2018 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.

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 advancing care information (ACI) 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 ACI 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 ACI 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 ACI 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	Advancing care information (ACI)	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 ACI 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.

Note:The MIPS decision support tool is for 2017 reporting. The 2018 tool is in development and will be available soon.

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 2017. 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

Tab 5

Note: The scenarios presented below are for 2017 reporting. Scenarios for 2018 MIPS reporting are in development and will be available soon.

Solo practitioner aims to avoid 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 patient 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. Ultimately 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 final decision after learning more about future penalties incurred from not using an EHR.

Although he has never participated in PQRS or meaningful use programs, cutting his Medicare Part B reimbursement by 5%, Dr. Smith did enroll in DataDerm, the AAD’s clinical data registry. Enrollment was free, 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, or 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.

WEIGHING THE OPTIONS

As a solo practitioner without an EHR, Dr. Smith realizes full MIPS participation is not possible. He must determine whether one of the less intensive reporting options is worth the effort or if he should take the penalty. Choosing not to participate in MIPS will result in over $80,000 in penalties over four years. Considering the cost of adopting an EHR system, he could very well stand to increase his revenue over the next five to seven years by increased MIPS participation through an EHR and clinical data registry.

To avoid the 4% payment penalty, he must report one quality measure at least one time.* While there will be a learning curve to submitting a quality measure through DataDerm, Dr. Smith believes navigating the new system with only one measure over a 90-day period is feasible.

*The AAD strongly recommends practices report more than one measure or report at least one measure over a 90-day period as an insurance policy in the event of submission issues or inaccuracies.

Option 1: No MIPS participation

4% penalty for non-participation in 2017 = $13,200
9% penalty for non-participation in 2020 = $29,700

Bottom line: Total penalty costs over four years = $82,500

Option 2: Minimal MIPS participation

Submit quality measure through DataDerm = $295/year
Physician’s time for data registry reporting (~5 hours/year) = $1,126
Total cost in 2017: $1,421

Bottom line: total cost by 2020 = $5,684
Neutral payment adjustment for 2017.

Option 3: Moderate MIPS participation

Submit quality measure through DataDerm = $295/year
Physician’s time for data registry reporting 2 quality measures = $2,252
Total cost in 2017: $2,547

Hypothetical increase of 0.5-1% earned in 2017: $1,650-$3,300

THE DECISION

Dr. Smith decides to avoid the MIPS penalty by reporting on the Biopsy Follow-Up quality measure for 90 days in 2017. He will need to report on 50% of applicable patients to meet this requirement.

Opting out of MIPS would cost him about $82,000 cumulatively through the 2020 reporting year, and with feasible reporting options for 2017, Dr. Smith finds no reason not to fulfill the minimum requirements and use the rest of 2017 to determine whether investing in an EHR system is worthwhile to meet future Quality Payment Program requirements.

After reviewing the option to report two quality measures for a moderate payment bonus in 2017, Dr. Smith decides that the cost and effort of additional reporting will not be worthwhile. Depending on his performance compared to CMS benchmarks, he most likely will not gain more than a 1% increase in pay for the 2017 reporting year.

Dermatology solo practice aims to receive 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, her business relies in large part on 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 a year in Medicare part B reimbursements.

At 45 years of age, Dr. Vasquez hopes to remain in practice for many years to come. She also expects her practice to continue to grow. As such, she realizes that she will eventually need to adopt an EHR system. With the introduction of the MIPS program looming, she feels that now may be the time. Dr. Vasquez knows that an EHR system will make it much easier to fulfill MIPS 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 a single quality measure recorded over a 90-day period. She also knows that she can report additional quality measures to qualify for an increase in reimbursements. 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 record and report each measure, for a total cost of $3380.64 ($1,126.88 times three) per measure submitted.

WEIGHING THE OPTIONS

Looking at her MIPS options for 2017, Vasquez rules out full participation, deciding that conducting such extensive reporting while adapting to a new EHR system would be too burdensome. That leaves three options to consider: (1) non-participation, (2) submitting one quality measure for a 90-day period to avoid penalty, or (3) submitting more than one measure in the hopes of receiving a modest increase in reimbursements.

Dr. Vasquez calculates the total cost and potential ROI for each option:

Option 1: No MIPS participation with payment penalty

4% penalty for non-participation in 2017 = $25,240
9% penalty for non-participation in 2020 = $56,790

Bottom line penalty costs over three years: $157,750

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 PA’s)
Staff time for reporting through EHR/DataDerm: $3,380.64 ($1,126.88 each for one derm and two PA’s)
Total cost in 2017: $47,765.64

Bottom line cost by 2020: $59,296.92

Option 3: Cost/benefit of reporting an additional measure

Additional staff time: $3,380.64
Hypothetical increase of 1% earned in 2017: $6,310*

*Actual increase based on comparison of measure score against CMS benchmarks

THE DECISION

Dr. Vasquez decides to adopt the EHR system and to report two measures for a potential modest incentive. The decision to adopt the EHR system is a no-brainer: avoiding the MIPS penalty for the first 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 will enjoy a wealth of future options under the MIPS program.

The decision to report one additional measure is a bit of a gamble because 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 0.5% would offset the extra staff time required, for an even break. Dr. Vasquez decides to take the risk. Not only may she earn a little extra if her scores are good, the experiment will be relatively low-risk and the results may help inform her future decision-making.

Dermatologists working 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 percent 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, vote for full participation in the MIPS program.

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 participated in the PQRS and MU programs 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 percent 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 take care of any fees 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 $3,000,000 in Medicare part B reimbursements.

Potential 4% incentive for the dermatology section under MIPS for 2017: $120,000
Bottom line for 2017: Dr. Gupta’s 2% bonus: $2,400

Cumulative potential incentive for dermatology section by 2020: $820,798.80
Bottom line by 2020: Dr. Gupta’s bonus may total $16,415.98

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 and MU, he is undaunted by reporting requirements. 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 MIPS participation, he makes a list of questions that will need to be answered by Quality Physicians. For example, he wants to know whether he will be expected to participate in any 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 MIPS incentive

Dr. Lee and Dr. Baker are the owning partners of Dermatology Associates of Richmond, a thriving group practice in a growing city. Their office includes five dermatologists — Dr. Lee, Dr. Baker, and three additional associates — supported by two PAs and two NPs. Together, the nine practitioners earn about $2,255,000 a year in Medicare part B reimbursements.

In preparation to begin 2017 MIPS reporting, Drs. Baker and Lee meet to discuss their options. They quickly rule out non-participation as this option carries an estimated penalty of $90,200 for the 2017 reporting year, ballooning to $202,950 in 2020. Such a heavy loss in revenue would be difficult for their business to sustain. Recently, they have had serious discussions about adopting an EHR system. Offsetting any potential penalties under MIPS could provide the justification to spend the estimated $60,000 the system will cost.

Drs. Lee and Baker are left with two options: partial participation in MIPS to achieve a small payment incentive, or full participation to qualify for a maximum incentive. Both options will require reporting, but the Dermatology Associates of Richmond are no stranger to reporting systems, having participated previously in the PQRS and MU programs. They also have enrolled free of charge in DataDerm^TM, the AAD’s clinical data registry. Adopting an EHR system may involve a learning curve, but they have time since they only need to report measures over a 90-day period.

WEIGHING THE OPTIONS

After conducting some additional research, Drs. Lee and Baker reconvene to crunch the numbers. They calculate ROIs for two scenarios: partial participation by reporting two quality measures and full participation. To qualify for the maximum incentive, they would need to submit six quality measures, one high-weighted Improvement Activity, and five Advancing Care Information (ACI) measures. For purposes of comparison, they also calculate the cost of non-participation.

Non-participation

4% penalty for non-participation in 2017: $90,200
9% penalty for non-participation in 2020: $202,950

Bottom line: Over three years, non-participation will cost practice $563,750

Option 1: Moderate participation

EHR adoption: $60,000
EHR upgrade fees per year: $1,500
Submitting quality measures through DataDerm: $2,655 ($295 X 9 practitioners)
Staff time for reporting two quality measures through EHR/DataDerm: $7,244.19 ($804.91 [five hours of staff time] for each of nine practitioners)
Total cost in 2017: $71,399.19
Total cost by 2020: $105,596.76
Hypothetical 1% incentive for 2017: $22,5501
Cumulative 1% incentive by 2020: $91,562.051

Bottom line: Net cost to practice over three years = $14,034

Option 2: Full participation

EHR adoption: $60,000
EHR upgrades per year (fulfilling ACI requirements): $1,648
Submitting quality measures through DataDerm: $2,655 ($295 each for five derms and four NPC’s)
Staff time for reporting six quality measures through EHR/DataDerm: $10,141.92 ($1,126.88 [seven hours staff time] for each of nine practitioners)
High-weighted Improvement Activity: No additional charge (reporting quality measures through DataDerm counts as a high-weighted Improvement Activity).
Total cost in 2017: $74,444.92
Total cost by 2020: $117,779.68
Maximum incentive for 2017: $90,200¹
Cumulative maximum incentive by 2020: $616,966.901

Bottom line: The practice would gain nearly $500,000 over three years

¹Actual increase will be based on comparison of measure score against CMS benchmarks.

THE DECISION

Drs. Baker and Lee agree that Dermatology Associates of Richmond should embrace full participation in MIPS in hopes of receiving a large incentive. Partial participation appears to be a sure money-loser in the first year, and full participation carries a significant risk of loss, due in large part to the initial outlay of adopting an EHR system. In both cases, however, the extra costs are significantly smaller than the penalty incurred for non-participation in MIPS.

Partial participation will continue to be a losing proposition. But full participation may put Dermatology Associates of Richmond on track for increasing profits over the next several years. Though there is no guarantee that the practice will receive the maximum incentive possible, it will 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:

Access the AAD's free Be MACRA Ready Webinar.
Download CMS' Technical Assistance Resource Guide for further help.

MACRA FAQs

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

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