MACRA 2018: Learn What’s New in Year 2

Posted on 3 May, 2018 |comments_icon 0|By Elizabeth

New in 2018: QPP Year 2 Eligibility

In QPP Year 2, eligible clinicians remain the same, and there is no change in Basic Exemption Criteria, but CMS reduces the number of providers and groups subject to the QPP by increasing the low-volume threshold. The CY 2018 Final Rule exempts providers and groups that are:

  1. New Medicare-enrolled eligible clinicians – If you enroll in Medicare for the first time during the performance period, you are exempt from reporting on measures and activities for MIPS until the following performance year. To be considered a new Medicare-enrolled eligible clinician, you cannot have previously submitted claims to Medicare under any other enrollment as an individual or through a group.
  2. Below the low-volume threshold – This means a clinician with either Medicare Part B allowed charges of less than or equal to $90,000 a year or who sees 200 or fewer Part-B enrolled Medicare beneficiaries a year. CMS will conduct low-volume status determinations prior to the start of the performance period and during the performance period using claims data.

                2018 Performance Period Determination:

For the 2018 MIPS performance period and the 2020 MIPS payment year, CMS will make low-volume status determinations based on satisfying either low-volume threshold in one of the following evaluation periods:

  • Historical claims data: September 1, 2016 – August 31, 2017
  • Performance period claims data: September 1, 2017 – August 31, 2018
  1. Significantly participating in Advanced APMs – This means clinicians who receive 25% of their Medicare payments through an Advanced APM or see 20% of their Medicare patients through an Advanced APM.

Providers and groups delivering service below these levels are exempt from participating in the QPP.


New in 2018: What’s New for Value Modifier Adjustments

In 2018, the Value Modifier will apply upward, downward, or neutral adjustments to payments made under the Medicare PFS to all physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs) in groups with two or more eligible professionals and those who are solo practitioners. Groups and solo practitioners are identified by their Medicare-enrolled TIN.

Bottom line: Physicians, PAs, NPs, CNSs, and CRNAs in groups and those who are solo practitioners can avoid the automatic downward payment adjustment in 2018 by either of the following:

  1. Participating in the PQRS group practice reporting option (GPRO) in 2016 and avoiding the 2018 PQRS downward payment adjustment
  2. Ensuring that at least 50% of the eligible providers in the group avoid the 2018 PQRS downward payment adjustment
  3. As a solo practitioner that avoids the 2018 PQRS downward payment adjustment by participating in the PQRS as an individual.

As with PQRS, the calendar year (CY) 2016 is the performance period for the Value Modifier that will be applied in 2018. Adjustment amounts will vary with the size and composition of the TIN.

How: Quality-tiering is the methodology that is used to evaluate a TIN’s performance on quality and cost measures for the Value Modifier and is mandatory for TINs subject to the Value Modifier in 2018. Under quality-tiering, TINs are eligible for upward or neutral adjustments under the 2018 Value Modifier based on their quality and cost performance in 2016.

Smart idea: To determine whether your TIN will be subject to an adjustment under the Value Modifier in 2018, access your TIN’s 2016 Annual Quality and Resource Use Report (QRUR) on the CMS Enterprise Portal at:

Way out: If your TIN is subject to the Value Modifier in 2018 and you disagree with the Value Modifier calculation indicated in your TIN’s 2016 Annual QRUR, then an authorized representative of your TIN can submit a request for an Informal Review through the CMS Enterprise Portal. Please refer to the 2016 QRUR and 2018 Value Modifier website for more information about the 2016 Annual QRURs, 2018 Value Modifier, and how to submit an informal review request. Please visit the CMS Value-Based Payment Modifier page at: for more information.

What’s on the Horizon for the Medicare Electronic Health Record (EHR) Incentive Program Adjustment?

The Medicare Electronic Health Record (EHR) Incentive Program provides incentive payments for certain healthcare providers to use EHR technology in ways that can positively impact patient care.

The program established incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs), and Medicare Advantage Organizations to promote the adoption and meaningful use of interoperable Health Information Technology (HIT) and qualified electronic health records (EHRs).

Under the EHR Incentive Program, CMS aligned several reporting requirements for those reporting electronically:

  • The electronic clinical quality measures (eCQM) specifications are used for multiple programs, including PQRS and the Medicare EHR Incentive Program
  • Satisfactory reporting of PQRS EHR quality measures allows individual eligible providers and PQRS group practices to satisfy the clinical quality measures (CQM) component of the EHR incentive program
  • Individual eligible providers and PQRS group practices are required to submit CQMs using a direct EHR product or EHR Data Submission Vendor that is Certified Electronic Health Record Technology (CEHRT)

If a healthcare provider is eligible to participate in the Medicare EHR Incentive Program, or both the Medicare and Medicaid EHR Incentive Programs, he must demonstrate meaningful use each year to avoid the Medicare payment adjustment.

Hospital-based EP’s are not subject to Medicare payment adjustments and are ineligible to receive an EHR incentive payment under either Medicare or Medicaid.

Medicaid healthcare providers who are only eligible to participate in the Medicaid EHR Incentive Program are not subject to payment adjustments.

New in 2018: EHR Adjustments May Cause Revenue Shortfalls

Watch out: For calendar year 2018 services, eligible providers who are not meaningful EHR users for an applicable EHR reporting period will be subject to a downward payment adjustment for covered professional services furnished in CY 2018.

Eligible providers that are subject to the EHR Incentive Program Medicare payment adjustment for CY 2018 should receive a separate notification from CMS via a United States Postal Service (USPS) letter. Instructions on how to apply for a reconsideration will be in this letter.

The payment adjustment is a -3% reduction to covered professional services billed under Medicare PFS in CY 2018.

Smart idea: Visit the “EHR Incentive Program Payment Adjustments and Hardship Exceptions” webpage at: for more information including fact sheets, forms, and reconsideration instructions.

New in 2018: CMS Introduces New Cost Category

For 2018, the Performance Category Weights for MIPS change to reflect the introduction of the Cost category this year instead of next year as CMS originally proposed. Refer to Table 3-2. Cost this year weighs in at 10%, so CMS is decreasing Quality’s weight to 50% to compensate. The other two categories, Advancing Care Information and Improvement Activities, remain at 25% and 15%, respectively.

Year 2 (2018 MIPS Performance Period):
50% Quality
15% Improvement Activities
25% Advancing Care Information
10% Cost

Tip: With the adoption of the Automatic Extreme and Uncontrollable Circumstance policy, CMS can automatically weigh the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by disasters such as hurricane Irma, Harvey and Maria and other natural disasters. We’ll review more about this policy later in this book.

New in 2018: Clinical Practice Improvement Activities Expand

The 2018 Final Rule implements 21 new Improvement Activities (some with modification) and changes 27 previously adopted improvement activities (some with modification and including one removal). These changes are effective for the Quality Payment Program Year 2 (CY 2018) and future years Improvement Activities Inventory.  We’ll review more later in this book.

Nail Down Improvement Activities Reporting

To determine what activities to report, go to the Improvement Activities page at and follow these CMS instructions:

  1. Review and select activities that best fit your practice:
  • Most participants: Attest that you completed up to four improvement activities for a minimum of 90 days.
  • Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to two activities for a minimum of 90 days.
  • Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
  • Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM: You will automatically be scored based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.
  • Participants in any other APM: You will automatically earn half credit and may report additional activities to increase your score.
  1. Download a CSV file of the activities you have selected for your records. The tool that CMS provides is for informational and estimation purposes only. You cannot use this tool to submit or attest to measures or activities.


New in 2018: Bonus Option for Advancing Care Information (ACI) Reporting

MIPS-eligible clinicians will have the option to report the Advancing Care Information Transition Objectives and Measures using 2014 edition CEHRT, 2015 edition CEHRT, or a combination of 2014 and 2015 edition CEHRT, as long as the EHR technology you possess can support the objectives and measures to which you plan to attest. Similarly, you will have the option to attest to the Advancing Care Information Objectives and Measures using 2015 edition CEHRT or a combination of 2014 and 2015 edition CEHRT, as long as their EHR technology can support the objectives and measures to which they plan to attest.

Need help identifying your electronic health record edition? Go to and search the official Certified Health IT Product List (CHPL). Each Complete EHR and EHR Module listed is eligible to be used for the Medicare and Medicaid EHR Incentive Programs and will be given a reporting number for that purpose. At the time of registration or attestation with CMS, eligible providers can use those reporting numbers as part of qualifying for EHR incentive payments.

New in 2018: CMS Announces Flexibility in Individual Reporting

CMS builds in additional flexibility for submitting data through multiple submission mechanisms. Individual MIPS-eligible clinicians or groups will be able to submit measures and activities, as available and applicable, via as many mechanisms as necessary to meet the requirements of the quality, improvement activities, or advancing care information performance categories for the 2019 performance period. This option will provide clinicians the ability to select the measures most meaningful to them, regardless of the submission mechanism.

Group Reporting With Payment Adjustments Based on Overall Group Performance

If you send your MIPS data with a group, the group will get one payment adjustment based on the group’s performance. A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site.

Your group will send in group-level data for each of the MIPS categories through the CMS web interface or an electronic health record, registry, or a qualified clinical data registry.

New in 2018: Lock Down Virtual Group Participation

You will also be able to participate in MIPS using virtual groups. Individual clinicians, as well as groups of 10 or fewer clinicians, will be able to form virtual groups. You will be required to indicate that you will be reporting through a virtual group prior to the start of the applicable performance period.

New in 2018: Ramp Up for Advanced APM Criteria Revisions

In 2018, an APM must meet the following criteria:

  1. Require participants to use certified electronic health record technology (CEHRT);
  2. Provide 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
  3. Either: (1) be a Medical Home Model expanded under CMS Innovation Center authority; or (2) require participating APM entities to bear more than a nominal amount of financial risk for monetary losses.

Tip: CMS applies a different Advanced APM financial risk criterion to Medical Home Models. In addition, MIPS-eligible clinicians participating in Medical Home Models automatically receive the full score for the MIPS improvement activities performance category.

To earn the 5% APM incentive payment, send quality data through your Advanced APM. Some Advanced APMs for 2018 include:

  • Comprehensive ESRD Care Model (CEC) (large dialysis organization-LDO arrangement and Non-LDO two-sided risk arrangement)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program (MSSP ACOs Track 2 and Track 3)*
  • Next Generation ACO Model
  • Oncology Care Model (only two-sided risk arrangement)

* MSSP Track 1 model requires participation in MIPS, but it is not considered an Advanced APM, and, therefore, is not eligible for the 5% bonus.

New in 2018: CMS Revises MIPS Improvement Activities

CMS posted an updated listing of MIPS Improvement Activities dated January 24, 2018 that you can find in the Appendixes section of this book. You should always check the Medicare Resource Library page at to get the most up-to-date information.

For Comprehensive MACRA Guidance

To learn more about MIPS and MACRA—and to stay on track for optimum reimbursement with strategies to avoid payment cuts in the coming years—pick up your copy of MACRA Quality Measures Guide 2018



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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