One of question is on top of every practice that have been accustomed to participating in Physician Quality Reporting System (PQRS), and it is exactly how Merit-based Incentive Payment System (MIPS) will affect their business. Yes, there has been significant updates under the new payment model, but it also inherits many of the characteristics of PQRS that most of the healthcare providers are familiar with.

In this blog, we have strived to break down the differences between the two to help you better understand the new payment system and prepare you for future reporting success.

The Key Differences Between PQRS and MIPS

Who will participate?

Clinical nurse specialist, NP, PA, physician (MD/DO and DMD/DDS) and certified registered nurse anesthetist who are not participating in an Advanced Alternative Payment Model (APM) fall under the gambit of MIPS for the first year.

What is Small Practice Exemption?

If your practice has less than or equal to $30,000 in Medicare charges, or treat fewer than or equal to 100 Medicare beneficiaries, you will be exempted from the gambit of MIPS.

How Will GPRO Work?

Previously you were supposed to register under the Group Practice Reporting Option (GPRO) in advance to report as a group, but not anymore, unless you are using CMS Web-Interface for submitting. Also, under Meaningful Use (MU), there was no provisions to report as a group, but now you have a way out. However, please note that if you opt to report as a group in any one of the MIPS categories, you must do the same for all the categories.

How is Registry Involvement Impacted?

Going forward, registries can submit for the three performance categories of the new payment model, i.e. quality, advancing care information and improvement activities. Also, registries for the first time can submit the EHR measures for the Quality category.

How is the Final Score Determined?

Your performance will be weighed and summed-up under four categories to form your Final Score. How your Final Score shapes up against the threshold score set by CMS each year will determine whether you will be eligible for an incentive or a penalty.

Here is a break-up of existing and new reimbursement model along with weightage that each of the new performance categories carry during the initial transition period:

PQRS and MIPS Reimbursement Model

MIPS Final Score 2017

4 Performance Categories Under MIPS


Accounting for 60% of your Final Score, the Quality category replaces PQRS and CMS-calculated measures under the Value Modifier (VM).

Resource Use (Cost)

Though this performance category will not carry any weightage initially, it is likely to carry a major weightage going forward. For instance, by 2019, this performance category will account for 30% of your Final Score.

Improvement Activities

Accounting for 15% of the Final Score in 2017, this category is intended to reward practices that focuses on continuous improvement.

Some of the improvement efforts that will be rewarded under this category will include:

  • Extended hours
  • Patient safety
  • Beneficiary engagement
  • Care coordination

Advancing Care Information

Accounting for 25% of the Final Score in 2017, this category replaces Meaningful Use (MU) or the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals.

Note: Meaningful Use for Hospital and Medicaid will be continued.

Weight of Performance Category Changes by Year


What Early Starters Think about MIPS When Compared to PQRS?

Clinicians who have long worked with PQRS for medical billing and coding purposes have found MIPS to be quite similar. The biggest difference that they have witnessed is the increased quantity of data or information that needs to be submitted under the new payment system. Additionally, they were extremely pleased with the flexible pacing options offered for the initial year of MIPS and were of the opinion that long years of reported under PQRS was of great help in adapting to the new program.

Here are some of the best practices that they recommend to succeed under the new payment regime:

  • Stay informed and be organized
  • Start early and build reporting into your routine
  • Opt for the correct reporting method and partner
  • Use the transition year to come up with a solid strategy and be prepared for increased requirements in the future

Other Best Practices that You Have to Implement for Successful PQRS to MIPS Transition

Apart from the best practices recommended by early starters, here are some of the things that you need to do as a MIPS-eligible clinician to earn positive payments adjustments in 2019 and beyond.

Review and understand your 2016 Quality and Resource Use Report (QRUR): Have a detailed analysis of your 2016 Annual QRUR and the CMS resource, “Understanding Your QRUR,” so that you are informed and up-to-date about the many ways in which you can use that information going forward.

Determine your MIPS eligibility: Last year was the “transition year” from PQRS to MIPS transition and CMS had exempted many small practices from the latest payment adjustments. But this requirement will change year over year. Hence make sure that you go through the requirements for MIPS eligible clinicians, as well as the exemption criteria, to know where you stand and what you must do this year to avoid a 4 percent negative payment adjustment going forward.

Document all patient encounters in the EHR: MIPS program is designed to reward those practices that use latest healthcare IT services to provide high-quality care and this applies to all the patients, not just patients that use Medicare Part B. One of the easiest way to receive this reward is by giving utmost importance to documentation and ensuring that every patient interaction is thoroughly documented using the latest EHR software and practices.

The Bottom-line

The updates in the latest Medicare quality reporting program are significant and can be too hot to handle for many organization. However, a professional help provided by an expert healthcare back-office support provider such as MedBillingExperts, can go a long way in navigating through the rigors of MIPS transition and preparing you for the future of the new Quality Payment Program. Contact us today to know how we can help you stay ahead of the curve in the industry.


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