Glossary of MACRA Terminology

Advanced Alternative Payment Model (Advanced APM)

An alternative payment model (APM) that has been certified by CMS to meet the following criteria:

  • Requires participants to use certified electronic health record technology (CEHRT);
  • Provides payment for covered professional services based on quality measures comparable to those used in the Quality performance category of the Merit-Based Incentive Payment System (MIPS); and
  • Is either a Medical Home Model expanded under CMS Innovation Center authority OR requires participating APM entities to bear more than a nominal amount of financial risk for monetary losses.
Alternative Payment Model (APM)

An APM is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to their patients' outcomes. Participants may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM.

Certified EHR Technology (CEHRT)

Certification of health IT assures purchasers and other users that an electronic health record (EHR) system or other relevant technology offers the technological capability, functionality, and security to help them meet the meaningful use criteria established for a given phase.

Eligible Clinician (MIPS)

CMS defines MIPS eligible clinicians as physicians (as defined in section 1861(r) of the Social Security Act), physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill under Medicare Part B. This does not include providers, such as clinical social workers, physical and occupational therapists, and others who might have been reporting quality measures under the PQRS for a number of years. CMS will consider expanding the definition of eligible clinician to these other professionals in Year 3 of the program.

Exclusions. Clinicians expressly excluded from MIPS include:

  • Qualifying Participants in Advanced APMs
  • Low-volume clinicians, defined as group practices and clinicians who bill less than or equal to $30,000 in Medicare Part B allowed charges OR have less than or equal to 100 Medicare patients. CMS intends to notify clinicians who fall under the low-volume threshold in early 2017.
  • Clinicians who newly enroll in Medicare during the performance period and have not previously submitted Medicare claims as an individual, part of a group, or under a different tax identifier.

For the 2017 performance period, CMS estimates that about 20% of MIPS eligible cardiothoracic surgeons will not be eligible for MIPS due to these exclusions.

Hospital-Based Clinicians. It’s important to note that CMS expanded its definition of “hospital-based” clinicians under MIPS to include those who furnish 75% or more of their covered professional services in sites of service identified by inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room (POS 23) setting. Although these clinicians are not explicitly excluded from MIPS, they are not required to comply with the advancing care information (ACI) portion of MIPS, discussed below. If a hospital-based clinician opts not to participate in the ACI portion of MIPS, CMS will redistribute the weight of this category to the Quality category. 

Medicare Access and CHIP Reauthorization Act (MACRA)

MACRA ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. If you participate in Medicare Part B, you are part of the dedicated team of clinicians who serve more than 55 million of the country’s most vulnerable Americans, and the Quality Payment Program will provide new tools and resources to help you give your patients the best possible care. You can choose how you want to participate based on your practice size, specialty, location, or patient population.

The new Quality Payment Program has two tracks you can choose:

Merit-Based Incentive Payment System (MIPS)

MIPS consolidates elements of legacy Medicare physician quality programs (Physician Quality Reporting System, the Value Modifier, and the EHR Incentive Program) into one new streamlined program. Under MACRA, CMS is required to evaluate clinician performance based on the following four categories:

MIPS Composite Score

MIPS Composite Scores will be based on a scale of 0–100 points. Clinicians and groups will be able to earn up to a certain number of points within each MIPS category, depending on how they perform.

Pick Your Pace Program

The first year that eligible clinicians will be required to comply with MIPS is 2017. Performance in 2017 will determine Medicare payment adjustments to these clinicians in 2019. Recognizing variation in readiness to engage in this new quality reporting program, CMS has declared 2017 a transition year where clinicians may “pick their pace” of participation in MIPS.

Options include: 
1. Reporting nothing, which will result in the maximum penalty of -4% in 2019 on all Medicare allowed charges.

2. “Testing” the new system by reporting the bare minimum to avoid a penalty in 2019. To avoid a penalty, a clinician or group practice may report: 
• One Quality measure, on as few as one patient, so long as performance is “met” on that measure; OR
• One Improvement Activity; OR
• The required “base” ACI measures, which could be 4 or 5 measures depending on which edition of certified EHR technology (CEHRT) is used.

Cardiothoracic surgeons reporting under this option may collect data on these measures or activities at any point in 2017, and there is no minimum reporting period associated with this option. However, keep in mind that this option will only allow them to avoid the 2019 MIPS penalty. It does not qualify them for any upward payment adjustment.

3. At a higher level of participation, cardiothoracic surgeons who report on more than what is required to avoid the penalty will be eligible for a neutral or small upward adjustment in 2019. Those who comply fully with the reporting requirements for multiple MIPS categories for a minimum of 90 days will have a greater chance of performing better and earning more points towards their overall MIPS Composite Score, which could translate into a higher upward payment adjustment in 2019. Since the minimum performance period for 2017 is 90 days, cardiothoracic surgeons have until October 3 to initiate participation in MIPS, but are encouraged to begin participating as soon as possible. 

4. On the highest end of the spectrum, those who fully satisfy the requirements of multiple MIPS performance categories and perform above a certain threshold in 2017, have the potential to receive not only a larger upward payment adjustment, but also an additional upward payment adjustment reserved for exceptional performers.

Qualified Clinical Data Registry (QCDR)

A qualified clinical data registry (QCDR) is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. To be considered a QCDR, an entity must self-nominate and successfully complete a qualification process.

A QCDR will complete the collection and submission of quality measures data on behalf of Eligible Professionals (EPs). The STS National Database is a QCDR and is available to STS members participating in the Adult Cardiac Surgery Database as a Medicare quality reporting option.

Qualifying Participant (QP)

An eligible clinician may become a QP or a Partial QP by participating in an Advanced APM in which the eligible clinicians as a group meet specific payment or patient thresholds.

During each QP Performance Period (corresponds to a calendar year), CMS would determine if an eligible clinician met one of the thresholds to become a QP or Partial QP.

QP/Partial QP status determinations would be made collectively for all eligible clinicians participating in each Advanced APM Entity. If the collective calculations demonstrate that a group meets the QP or Partial QP Payment Amount Threshold or QP or Partial QP Patient Count Threshold, all of the group’s eligible clinicians would achieve QP or Partial QP status, respectively.

The QP and Partial QP determination payment thresholds change over time: 

  • 2019 and 2020: at least 25% of the eligible clinician group’s Medicare Part B fee-for-service (FFS) covered professional services payments (Medicare Option)
    • The Partial QP threshold is 20%.
  • 2021 and 2022: at least 50% of Medicare Part B FFS covered professional services payments (Medicare Option) or at least 50% of All-Payer payments (with at least 25% of Medicare payments) (All-Payer Option)
    • The Partial QP Medicare Option threshold is 40% of the Partial QP All-Payer Option thresholds are 40% total, with at least 20% Medicare.
  • 2023 and beyond: at least 75% of Medicare payments (Medicare Option) or 75% of All-Payer payments (with at least 25% of Medicare payments) (AllPayer Option)
    • The Partial QP Medicare Option threshold is 50%
    • The Partial QP All-Payer Option thresholds are 50% total, with at least 20% Medicare. 

CMS will also make QP and Partial QP determinations each year using patient counts. Preliminary analysis by CMS shows that the proposed QP/Partial QP payment and patient count thresholds yield results that are very similar.

Quality Payment Program (QPP)

The Quality Payment Program improves Medicare by helping you focus on care quality and the one thing that matters most—making patients healthier. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. If you participate in Medicare Part B, you are part of the dedicated team of clinicians who serve more than 55 million of the country’s most vulnerable Americans, and the Quality Payment Program will provide new tools and resources to help you give your patients the best possible care. You can choose how you want to participate based on your practice size, specialty, location, or patient population.

The Quality Payment Program has two tracks:

Specialty Measure Set

Measure sets are simply suggested subsets of MIPS measures that CMS believes are most applicable to a specific specialty.

Last updated: 8/29/2017