By: Teri Thurston, Billing & Coding Advisor, PECAA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate (SGR) formula, that would have resulted in a significant cut in payment rates to optical physicians. MACRA requires CMS to establish an alternative incentive program, referred to as the Quality Payment Program. This program provides two pathways to participate, the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment models (APMs). The majority of physicians continue to participate under MIPS.

The first two years of MIPS were implemented gradually to reduce burden and provide flexibility in how physicians could participate. In November, CMS released the Final Rule for year 3 of the Quality Payment Program (QPP), revising payment policies under Medicare Part B for the 2019 calendar year. Year 3 continues to focus on simplification, reducing burden and meaningful quality outcomes for patients while streamlining reporting for optometry doctors.

Low-volume Threshold to Participate

To qualify under the MIPS track you must meet all three of the low-volume threshold criteria as an individual.

  • Bill more than $90,000 a year in allowed Medicare Part B service charges
  • See 200 Medicare beneficiaries a year
  • Provide more than 200 covered professional services.

If you meet all three criteria you will be automatically enrolled and required to participate for 2019. Utilizing 2015 CEHRT will also be required starting January 1, 2019 for full year reporting.

Excluded from Participation:

You are automatically excluded from MIPS if you enrolled in Medicare for the first time in 2018, or if you do not meet all three above criteria.

Optional Participation:

For 2019 you may opt-in to participate if you meet at least 1 of the above low-volume threshold criteria. For example, if you billed 200 professional services, but did not see 200 Medicare patients or bill $90,000 in charges you may still participate. If you wish to opt-in simply report your data to CMS by one of the reporting methods (or submission types) for 2019. Caution, if you do not wish to participate be sure to not inadvertently submit claims data to Medicare. This has the potential to enroll you into the program. Once you opt-in you must participate.

To check your participation status, go to and enter your 10-digit Nation Provider Identifier (NPI).

MIPS Performance Measures

MIPS is comprised of four pillars that affect how you will be paid by Medicare (Quality, Promoting Interoperability (formerly Advancing Care Information), Improvement Activities and Cost). Each performance categories have separate reporting requirements and associated maximum point totals to make up your final MIPS score.

The scoring for 2019 has changed to the following revised performance categories for Year 3, making up 100 possible final score points.

Quality 45%

This performance category replaced PQRS in 2017. This category covers the quality of the care you deliver, based on performance measures you pick. Select a minimum of six measures of performance that best fit your practice. The Quality measures for 2019 will count 45% of your total MIPS score in 2019, down from 50% in 2018. The Quality performance reporting period for 2019 is a full 12-months (January 1, 2019 to December 31, 2019).

Promoting Interoperability (formerly Advancing Care Information) 25%

PI replaces the Medicare EHR Incentive Program, commonly known as Meaningful Use. In this performance category, you choose measures to advance the productive use of the healthcare information you create. This is done by proactively sharing information with other clinicians or the patient in a comprehensive manner. This may include: sharing test results, visit summaries, and therapeutic plans with the patient and other facilities to coordinate care. The PI measures for 2019 will remain 25% of your total MIPS score. PI is minimum 90-day reporting period and you must be utilizing 2015 CEHRT to participate. To maximize your opportunities, ensure your EHR is updated to the appropriate software version by January 1, 2019.

Improvement Activities 15%

This performance category includes activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. Choose the activities appropriate to your practice from categories such as:

  • Enhancing care coordination
  • Patient and clinician shared decision-making
  • Expansion of practice access.

The IA for 2019 will remain 15% of your total MIPS score. There are new measures available for IA, as well as some deleted measures from 2018. Review the new measure to ensure you are reporting on the best measures for your practice.

Cost 15%

This performance category replaces the value-based modifier (VBM). The cost of the care you provide will be calculated by CMS based on your Medicare claims. There is no active reporting to submit for this measure. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. For 2019, this performance category will count 15% towards your MIPS final score, up from 10% in 2018.

Financial impact:

The 2019 MIPS incentive payment formula is based on a 100 points maximum (Quality = 45 points, Cost = 15 points, PI = 25 points, IA = 15 points). The MIPS score earned in the 2019 performance year determines the percentage adjustment applied to Medicare Part B payments during the 2021 payment year. You must score a minimum of 30 points to avoid the penalty, this is up from 15 points is 2018. If you score 29 points or less there is a 7% downward payment adjustment applied to Medicare Part B payments in 2021. If 30 to 74 points is achieved, you will avoid any penalties and have the potential to earn up to 7% upward incentive payments in 2021. If you achieved 75 to 100 points you will receive the 7% payment increase in 2021. There is $500 million available each year for incentive payments. The number of participate that meet or exceed the exceptional performance level of 75 to 100 points will determine the amount to be shared with clinicians that fall in the 30 to 74 points range.

Things to consider as 2019 moves closer:

  • Review and select measures that will be most meaningful to your optometric practice and patient population.
  • Check with your software vendors to determine which measures can be tracked and submitted electronically through your EHR.
  • If utilizing a registry such as AOA MORE or IRIS, review the 2019 measures available through the registry.
  • Verify that your EHR and the registry are still compatible for 2019 data submission.

To download 2019 MIPS resources, including the 2019 QPP Final Rule Fact Sheet, the CY 2019 Updates to the Quality Payment Program and the Virtual Group Participation Fact Sheet, please fill out the form below.




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We would welcome the opportunity to speak with you directly to find out how we can help serve your needs. Please fill out an inquiry form here and a representative will be in touch with you soon. Or, simply e-mail Teri Thurston at or by calling 503.670.9200.

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