The Centers for Medicare and Medicaid Services (CMS) has proposed that clinician consultation of Appropriate Use Criteria (AUC) for advanced imaging services be a high-weighted improvement activity under the Merit-Based Incentive Payment System (MIPS).

The provision is part of the recently released CMS proposed rule on the 2018 Quality Payment Program established under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015).

In this rule CMS describes changes it proposes to make to policies for implementation of the second transition year for the Merit-Based Incentives Payment System (MIPS) and for Advanced Alternative Payment Models (APMs).

CMS will recognize the improvement activity for physicians who attest they are using AUC through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered. Early adopters of AUC will be eligible to begin reporting this activity in 2018 while other clinicians will begin in future years as required under the Protecting Access to Medicare Act.

Other areas of interest in the proposed rule are the easing of requirements for small and rural practices by lowering the threshold for physicians being exempt from the QPP if they bill for less than or equal to $90,000 to Medicare or treat less than or equal to 200 patients per year. In addition, there are other provisions that make it easier for small and rural practices to get awarded points and have opportunities to earn additional bonus points under QPP.

CMS plans to implement the use of virtual groups and defines them as being composed of solo practitioners or groups of 10 or fewer eligible clinicians who come together virtually to participate in MIPS. This would allow for small and rural practices to join other small groups and jointly work towards meeting MIPS requirements if they are determined to be MIPS eligible. The definition of patient-facing would be the same for these groups as it is currently defined for individuals and groups for 2017.

CMS is proposing that the cost category under MIPS that is currently set to zero, and thus is not used to calculate a physician’s performance score for 2017, continue to be set at zero for 2018. The 10% that would have been allocated to the cost category for 2018 would instead be shifted to the quality category totaling 60%. The other MIPS category percentages would be 25% for advancing care information and 15% for improvement activities. If physicians reweight (i.e., exempt) the ACI (Advancing Care Information) category then the 25% would be reallocated to the quality category.

CMS also proposes a new alternative that would allow reallocating those ACI points partially to the quality category and partially to the CPIA category, thus lessening the emphasis on quality scores for those who reweight ACI.

In last year’s QPP final rule, CMS created several different ACI reweighting/exemption options, including one for “hospital-based” eligible clinicians who perform 75% or more covered professional services in the inpatient hospital, on-campus outpatient hospital and/or emergency room settings. In this year’s proposed rule, CMS proposes to extend the hospital-based determination to include off-campus outpatient hospital settings (POS 19). CMS is also proposing new reweighting/exemption options, including one for small practices who face an overwhelming barrier to ACI compliance.

Finally for APMs, Medicare keeps the same qualifying performance periods for participants. Medicare also proposes to extend the revenue-based nominal amount standard for two more years which allows APMs to meet the financial risk criterion for APM participants to bear a total risk of 8% of Part A and Part B revenues.

The ACR MACRA Committee and staff are reading and digesting this rule and will prepare a more detailed summary for publication in the near future. In the meantime, read the CMS extensive fact sheet on the major proposed changes in this rule for the second year of Medicare’s Quality Payment Program for physicians who are required to participate in either APMs or MIPS.