MACRA, QPP, MIPS, APM - What these Mean for You

What is MACRA?

What is Macra? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.

MACRA includes several changes to the way reimbursement of medical services is made. It introduces a payment method that incentives value and quality of care over volume, known as the Quality Payment Program (QPP).

What is the Quality Payment Program (QPP)?

The Quality Payment Program is aimed to provide new tools and resources to incentivize providers of medical services to give their patients the best possible care.

The Quality Payment Program has two tracks:

Advanced Alternative Payment Models (APMs) or
The Merit-based Incentive Payment System (MIPS)

Clinicians can participate in the APMs or in MIPS to avoid downward payment adjustments and potentially receive upward adjustments.

Schedule? (it is happening now!)

The election period for electing the Quality Payment Program is from October 11, 2017 to December 1, 2017.

The performance period for MIPS begins January 1, 2017, and the first payment adjustments will be applied in 2019.

Merit-based Incentive Payment System (MIPS)

MIPS allows Medicare clinicians to be paid for providing high-quality, efficient care measured by four performance categories, which will be weighted as follows:

	Performance Category	Description	% of Overall MIPS Score. Year 1 = 2017
1	Quality	Clinicians choose six measures to report to CMS that best reflect their practice. One of these measures must be an outcome measure or a high-priority measure.	60%
2	Advancing Care Information	Clinicians will report key measures of interoperability and information exchange. Clinicians are rewarded for their performance on measures that matter most to them.	25%
3	Clinical Practice Improvement Activities	Clinicians can choose the activities best suited for their practice, of more than 90 pre-defined activities. Clinicians participating in medical homes earn full credit in this category, and those participating in Advanced APMs will earn at least half credit.	15%
4	Cost	CMS will calculate these measures based on claims and availability of sufficient volume. Clinicians do not need to report anything.	0% (until 2018)

What Quality Measures Are Most Relevant to Diagnostic Radiology?

The quality measures tables below, published by ACR, contain instructions for reporting MIPS measures

Measure #	Title	Description
145	Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy	Percentage of final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time AND number of fluorographic images (if radiation exposure indices are not available)
146	Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening	Percentage of final reports for screening mammograms that are classified as “probably benign”
195	Radiology: Stenosis Measurement in Carotid Imaging Reports	Percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram ) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement
225	Radiology: Reminder System for Mammograms	Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram
265	Biopsy Follow-Up	Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
322	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients	Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12- • Updated Instructions month reporting period
323	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)	Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status
324	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients	Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment
359	Optimizing Patient exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for CT Imaging Description	Percentage of CT imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems
360	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: CT and Cardiac Nuclear Medicine Studies	Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study
361	Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index	Percentage of total CT studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements
362	Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison	Percentage of final reports for CT studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12- month period after the study
363	Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive	Percentage of final reports of CT studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities
364	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines	Percentage of final reports for CT imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
405	Appropriate Follow-up Imaging for Incidental Abdominal Lesions	Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended: • Liver lesion ≤ 0.5 cm • Cystic kidney lesion < 1.0 cm • Adrenal lesion ≤ 1.0 cm
406	Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients	Percentage of final reports for CT, CT angiography (CTA) or MRI or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended
436	Radiation Consideration for Adult CT: Utilization of Dose Lowering techniques	Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique

Does CT radiation reduction and reporting play role in QPP?

Yes. Of the 18 specified measures, 7 are related to CT radiation reduction and reporting, accounting for approximately 40% of the entire measures.

References and resources

CMS Resources

ACR Resources

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