​​MACRA University

MACRA: Frequently Asked Questions

​1.  MIPS eligible groups reporting quality performance category measures need to all report on the same six measures, correct? This is true regardless of the group's size and specialty mix, correct?

Answer:  When reporting as a group, regardless of the size, 6 Quality Measures would need to be reported on for the Quality Category. Only groups of 25+ who choose to report via the Web Interface would need to report on 15 Quality Measures. If the practice is reporting as a group, then the group would collectively choose 6 different quality measures. If the practice reports individually, then all of the providers would need to choose their own 6 Quality Measures to report on. The providers can choose the same 6 quality measures if they would like, or they could choose their own measures as well.  (Source: CMS QPP Service Center 1-13-17)

​2.  It is my understanding that MIPS eligible clinicians are not required to determine whether they are reporting as a group or as individuals until the reporting deadline (currently March 31, 2018 for 2017 performance) correct?

Answer:  The determination to report as an individual or as a group under MIPS is up to each practice. You have the option to choose to report as individuals or as a group.

  • A group, as defined by Taxpayer Identification Number (TIN), would be assessed as a group practice across all 4 MIPS performance categories.  A group can also choose to report information individually for all the MIPS eligible clinicians in the practice. If you participate in MIPS as a group, you'll jointly report your measures data for all 4 performance categories, and generally, you will all earn the same performance score. Beginning in the 2018 performance period, groups of not more than 10 MIPS eligible clinicians can also participate in MIPS using "virtual groups."

Group reporting requires the participation of all the eligible clinicians billing Medicare through a single Taxpayer Identification Number (TIN), regardless of specialty or practice site. The following additional requirements apply:

  • 2 or more clinicians in the group, and at least one has to be an eligible clinician
  • Groups must be measured as a group for all 4 performance categories

Remember, if you participate as a group, you'll jointly submit your measures data for 3 performance categories, and be measured as a group for all 4 performance categories (the Cost Performance category doesn't require data submission). Group reporting will require data aggregation across the entire group, potentially across multiple specialties and practice locations.

Self-Nomination/Registration: Eligible clinicians submitting for the MIPS program as individuals would not need to specify this to CMS. If a Tax ID elected to submit MIPS as a group, there are only two situations where they would need to register by June 30, 2017 as a group:

  1. Choosing to submit MIPS data using the CMS Web Interface submission option
  2. Choosing to submit CAHPS for MIPS survey data

(Source: CMS QPP Service Center 1-11-17)

​3.  Does submitting a numerator/denominator of 1/1 meet the minimum requirement for the base ACI measures that require numerator/denominator reporting? 

​Answer:  MIPS eligible clinicians need to fulfill the requirements of all the base score measures in order to receive the 50% base score. If these requirements are not met, they will get a 0 in the overall Advancing Care Information performance category score.

In order to receive the 50% base score, MIPS eligible clinicians must submit a "yes" for the security risk 
analysis measure, and at least a 1 in the numerator for the numerator/denominator of the remaining 

The base score Advancing Care Information measures are:
1. Security Risk Analysis
2. e-Prescribing
3. Provide Patient Access
4. Send a Summary of Care
5. Request/Accept Summary of Care

 The base score 2017 Advancing Care Information transition measures are:
1. Security Risk Analysis
2. e-Prescribing
3. Provide Patient Access
4. Health Information Exchange

As explained above, all of the base score requirements must be met in order to receive the 50% base 
score and be able to receive a score in the Advancing Care Information category.  In addition, it is important to note that some of the base score measures can also contribute towards the 
performance score. 

(Source CMS QPP Service Center 1-6-17)

4.  If a multi-specialty group of eligible clinicians chooses 20 quality measures to report, to cover all specialties, and they submit all 20, CMS will determine the performance score for the whole group based on the 6 measures that have the highest performance, correct?  If this is accurate, then it is possible that some of the clinicians in specialties with low performance on their measures will not have their performance data contribute to the MIPS Composite Performance Score, correct?

Answer:  First question: Yes, this is correct (top five highest performance + one outcome (or one high priority if an outcome is not available).

Second question: Correct – see previous response.  In addition, if reporting as a group, you would report the same measures across the entire TIN for all applicable patients regardless of the individual rendering NPI.

(Source: CMS QPP Service Center 12-22-16)