Anesthesia & Pain Management Compliance Auditors

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MIPS Update

CMS is in the process of sending providers notification of their eligibility to report MIPS; telling providers if they qualify for MIPS reporting based on the number of patients and total dollars billed to Medicare.


The letters being sent provide information both for the group as a whole, and for each individual within the group.  These letters communicate whether the provider is exempt from MIPS this year based on either: 1) falling below a low-volume threshold (less than or equal to $30,000 in Medicare Part B allowed charges OR 100 or fewer Medicare patients) during a prior determination period; 2) not being among the categories of clinicians included this year; or 3) being a new Medicare enrolled clinician.


It is our understanding that the letters do not indicate non-patient facing or hospital-based determinations, which will impact whether practitioners are required to submit data for the Advancing Care Information component of MIPS, which replaced Meaningful Use. Those determinations are still forthcoming.


If you want to determine the MIPS classifications yourself for a comparison to what CMS has sent, I have outlined the steps below.

Determine the MIPS status for each provider and the group.

  • There are two (2) determination periods.  First is September 1 – August 31 of the previous year and the second is September 1 – August 31 of the performance year.  So for 2017, the dates of service included in the first reporting period are September 1, 2015 – August 31, 2016.  The first determination period will determine the provider/group classification for the upcoming performance year.  The second reporting period will include dates of service September 1, 2016 – August 31, 2017.  The second determination period will be used to identify new eligible clinicians and set the provider/group classification for the following performance period.
  •  Prepare a custom report that could be run annually to assist in determining MACRA participation and MIPS status and reporting classifications.  The report should include the following information:
    • Tax Identification Number (TIN)
    • Provider NPI Number
    • Provider Name
    • Total Number of Services
    • Total Allowed Amount for All Services
    • Total Number of Medicare Cases (<=100 Cases will exclude the provider from MIPS for 2017)
    • Total Allowed Amount for Medicare Cases (<=$30,000 will exclude the provider from MIPS for 2017)
    • First Year Enrollment in Medicare (Y/N) – Is this the first year the provider will report to Medicare, i.e., is this a new provider to Medicare – not to the group?
    • Total Number of Medicare Patients
    • Total Number of Medicare Patients Serviced Through a Qualified Advanced Alternative Payment Model (APM) (20% or more of your Medicare Patients must be billed through the APM to qualify for APM participation instead of MIPS)
    • Total Allowed Amount of Medicare Payments Through a Qualified APM (25% or more of your Medicare Payments must be received through the APM to qualify for APM participation instead of MIPS)
    • Total Number of Patient-Facing Encounters (Billed CPT codes for E&M services and procedural services excluding A-Line, TEE, Spinal, TAP blocks, and ultrasound guidance).  For the complete list of Patient-Facing Encounter codes go to and access the document ‘Quality Measure Encounter Codes’. (>100 classified as a Patient-Facing Provider; <=100 classified as a Non-Patient-Facing Provider; For a Group to be classified as Non-Patient-Facing, 75% or more of the individual providers must meet the Non-Patient-Facing Encounters <= 100 requirement.)
    • Total Number of Hospital-Based Services (services provided with the Place of Service (POS) of 21, 22, or 23).  Please note that Place of Service 24 (Ambulatory Surgical Center or 19 (Off-Campus Outpatient Facility) are not defined in the Hospital-Based Services.
    • Percent of Hospital-Based Services: Total Number of Hospital-Based Services / Total Number of Services. (>=75% classified as Hospital-Based; <75% classified as Non-Hospital Based.)
A few additional notes, the above test will also give you the information you will need to determine your status as Hospital-Based or Patient-Facing Providers which we understand should also be coming shortly.  This will tell you whether you must submit measures under the Advancing Care Information Category.


CRNAs and AAs are exempt in 2017 for the Advancing Care Information Category.


Hopefully armed with this information you will be able to confirm or deny the status Medicare provided to you in the CMS letter.  If you have any questions we at ACE are happy to help.


Lynette Peterson, CHA, CHC