IF YOU provide care to Medicare patients, and you haven’t already, you want to acquaint yourself with MACRA, or the Medicare Access & CHIP Reauthorization Act of 2015. The reason: It has changed the way Medicare Part B providers are reimbursed.

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Here, we provide a review of MACRA, what will change for 2018 and how you can maximize your 2018 score.


MACRA is the first step toward outcome-based reimbursement and replaced the fee-for-service system. Specifically, it bases reimbursement on a provider’s performance in categories focused on quality and better outcomes. (Also, MACRA ended the sustainable growth rate formula enacted in 1997, which threatened large payment cuts to Medicare reimbursements for the past 13 years.)

The Quality Payment Program (QPP), under MACRA, was created to enable providers to decide how to participate based on their practice size, specialty, location and patient population. Two participation pathways were established under QPP: (1) Advanced Alternative Payment Models (APMs) and (2) the Merit-based Incentive Payment System (MIPS). CMS designated MIPS as the default pathway for all providers and as the best pathway for O.D. participants, as the government agency estimated that approximately 0.1% of optometrists eligible for MACRA would qualify to participate in the APMs. MIPS 2017 had the following weighted categories: Quality (60%), which replaced the Physician Quality Reporting System (PQRS), Cost (0%), which replaced the Value-Based Modifier, Advancing Care Information (25%), which replaced the Meaningful Use program, and Clinical Practice Improvement (15%) which is a new category.

CMS requires the following for participation in the first MIPS performance period: The provider is a physician (O.D.), physician assistant, nurse practitioner, clinical nurse specialist or a certified registered nurse anesthetist, and he or she is a provider for Medicare, who billed Medicare more than $30,000 in Part B-allowed charges and provided care for more than 100 Medicare patients a year. CMS created for providers to enter their NPI number to assess their MIPS eligibility status. The government agency then created an initial eligibility determination period, which was Sept. 1, 2015 to Aug. 31, 2016, and it re-evaluated eligibility during a second determination period, which was from Sept. 1, 2016 to Aug. 31, 2017.

A composite score is produced by totaling the provider’s scores for each of the four weighted categories, or Quality + Cost + ACI + CPI, determining whether the participant has an increase, decrease or neutral payment adjustment on the Medicare Part B base payment fee schedule for the first performance period, which started Jan. 1, 2017 and ends Dec. 31, 2017. This final score is represented by a scale of 0 to 100. Eligible providers must submit their data by March 31, 2018. The 2017 performance year determines your adjusted fee schedule two years later, or for the calendar year 2019. As a result, the first payment adjustments based on 2017 performance go into effect on Jan. 1, 2019.

To avoid the downward payment adjustment in 2019 Medicare Part B payments, an eligible provider must score at least three points. Those who have final scores between four and 69 points will receive a small positive payment adjustment, and those with final scores greater than or equal to 70 points will receive a modest positive payment adjustment and will be eligible for an exceptional performance bonus.

CMS deemed 2017 a transitional year for MIPS, allowing providers to “Pick Your Pace” to help them gain familiarity with the QPP. Under the “Pick Your Pace” concept, CMS allows participation for the full year (submit data for the entire 2017 calendar year), partial-year participation (submit data for any 90-day period after Jan. 1) and a test pace (submit data for one quality measure, for one patient, for one day, one improvement activity or the base objectives for Advancing Care Information). Those included in the QPP for 2017 who chose not to participate in the first MIPS performance period, will receive the maximum negative payment adjustment in 2019, which is a 4% payment reduction of all their 2019 Medicare Part B reimbursements.

MIPS participation tracking is based on participation type. So, if an eligible provider participates in MIPS as an individual, CMS uses both his or her TIN and NPI. If an eligible provider practices in more than one location or he or she moved to a new practice, CMS assesses this person separately for each TIN his or her NPI was linked to. If an eligible provider participates in MIPS as a member of a group, the group’s TIN alone was that person’s identifier for all weighted categories. Payment adjustments will be applied at the TIN/NPI level regardless of whether one participated in MIPS as an individual or as part of a MIPS group.


For the second performance year in 2018, starting Jan. 1 and ending Dec. 31, the following changes will occur to MIPS:

  • Re-weighting of two categories. An eligible provider’s final 2018 MIPS score will be comprised of Quality (50%) and Cost (10%), while Advancing Care Information and Clinical Practice Improvement will remain at 25% and 15%, respectively. Further, there may be a possible score for improvement over the previous performance year in the Quality and Cost categories when data allows for comparison.
  • Eligibility. For 2018, the QPP will exclude individual clinicians or groups who have less than or equal to $90,000 in Part B-allowed charges or less than or equal to 200 Part B beneficiaries. This change will significantly increase the number of O.D.s who are excluded from participation in MIPS.

    Also, the QPP will include Virtual Groups as an option in 2018, allowing for the combination of two or more TINs made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together virtually to participate in MIPS (no matter specialty or location). The conditions for Virtual Groups: registration between Oct. 11 and Dec. 31 and both solo practitioners and groups participating in the Virtual Group must exceed the low volume threshold for 2018. (Virtual groups allow smaller participants in the QPP to increase their performance volume and, therefore, be more reliably scored.)
  • MIPS score bonus points for small practices. In 2018, the QPP will help practices that contain 15 or fewer eligible clinicians by adding five bonus points to these clinicians’ final MIPS score.
  • MIPS score minimum increase. To avoid the downward payment adjustment in 2020 Medicare Part B payments (the adjustment year for the 2018 performance year), an eligible provider must score at least 15 points, up from three points in 2017.


To accomplish this, let’s look at the weighted categories individually:

  • Quality (50%). You must report on at least six of the about 275 available quality measures. For the best chance at a high score, you should attempt to report quality measures that you encounter at least 20 times and that you have met at least 60% of the time during the reporting period. Of these six quality measures, at least one should be an outcome measure (if none is available, you may replace it with a high-priority measure). If you report more than six measures, CMS will determine which six will give you the highest quality score.

    For O.D.s, the most common reporting mechanisms for quality measures will be claims-based reporting, EHR direct reporting or registry (AOA MORE) reporting. When choosing measures to utilize, understand that some measures, such as AMD: Counseling on Antioxidant Supplement (claims/registry reporting only) and others, are only available for certain reporting mechanisms, as noted here. You may receive bonus points for reporting additional high-priority measures and doing so via your certified EHR technology. For a complete list of the Quality measures, visit .

    For 2018, the Quality category has a full-year reporting period requirement (90 days in 2017). Your total quality performance category score equals points earned on the required six measures in addition to bonus points/maximum number of points. (See “Examples of Quality Measures,” with reporting mechanisms available that are most applicable to optometry.)
  • Cost (10%). This includes the Medicare spending per beneficiary and total per capita cost measures, calculated automatically for the entire 2018 calendar year based on Medicare submitted claims.
  • Advancing Care Information (25%). The reporting for this is 90 consecutive days for 2018. This score is broken into two parts: (1) a base score (50%) and (2) a performance score (90%) plus possible bonus points. Your score will be capped at 100%, but this scoring system will allow you to score high without having perfect scores on each performance measure. Two measure sets are available for you to use.
  • Clinical Practice Improvement Activities. You will attest to which of the 112 activities — from nine subcategories — that you have completed for 90 consecutive days. For full credit, you must achieve 40 points. Each activity is given points based on medium weight (10 points) or high weight (20 points). Groups with more than 15 participants have these options for submission: two high-weighted, one high-weighted and two medium-weighted or four medium-weighted activities to receive full credit for this category. To continue to make this category easier for small practices (less than 16 participants), non-patient-facing clinicians and those in health professional shortage areas, these physicians will get double points for each activity completed (medium weight [20 points] and high weight [40 points]). Therefore, these groups would only need to submit one high-weight activity or two medium-weight activities for full credit.

Examples of Quality Measures

  • Diabetes: eye exam (report via claims, EHR, CMS web interface or registry)
  • Diabetic retinopathy: communication with the physician managing ongoing diabetes care* (report via claims, EHR, or registry)
  • Diabetic retinopathy: documentation of presence or absence of macular edema and level of severity of retinopathy (EHR reporting only)
  • Primary open-angle glaucoma (POAG): optic nerve evaluation (report via claims, EHR or registry)
  • POAG: reduction of IOP by 15% or documentation of a plan of care*+ (report via claims or registry)
  • AMD: counseling on antioxidant supplement (report via claims or registry)
  • AMD: dilated macular examination (report via claims or registry)
  • Use of high-risk medications in the elderly: (report via EHR or registry)
  • Controlling high blood pressure*+: (report via claims, EHR, CMS web interface, or registry)
  • Closing the referral loop: receipt of specialist report* (EHR reporting only)
  • Documentation of current medications in the medical record*: (report via claims, EHR or registry)
  • Preventive care and screening: tobacco use: screening and cessation intervention (report via claims, EHR, CMS web interface or registry)

* high priority measure; + outcomes measure


MACRA continues to undergo modification for the purpose of achieving better outcomes delivered with less time and cost to the patient and health care system. By familiarizing yourself with MACRA and your role as an eligible provider, you can benefit from the program, while your patients receive exceptional care. OM