Eligible Clinicians for MACRA: MIPS & APMs | Practice Fusion

As part of implementing MACRA regulations, CMS has outlined a plan to streamline existing Medicare programs like Meaningful Use, PQRS, and the Value Based Payment Modifier program in 2018 and combine many of their components into a single framework called the Quality Payment Program. The program has two paths:

• The Merit-based Incentive Payment System (MIPS).
• Advanced Alternative Payment Models (APMs).

Under new program regulations, CMS is replacing the term eligible professional, or EP, with eligible clinician, or EC. Find out if you’re an eligible clinician under the Quality Payment Program by reviewing CMS’ MIPS eligibility criteria below.

Who are the MIPS eligible clinicians?

CMS has proposed that a MIPS eligible clinician be defined as the following licensed providers and any group that includes such professionals:

MIPS Eligible Clinicians

• Doctors of Medicine (MD)
• Doctors of Osteopathy (DO)
• Doctors of Dental Surgery/Dental Medicine (DMD/DDS)
• Doctors of Podiatry
• Doctors of Optometry
• Chiropractors
• Physician Assistants (PA)
• Nurse Practitioners (NP)
• Clinical Nurse Specialists
• Certified Registered Nurse Anesthetists

After three years of MACRA, the US Secretary of Health and Human Services has the option to expand the definition of a MIPS eligible clinicians to also include:

• Physical Therapists
• Occupational therapists
• Speech-language pathologists
• Audiologists
• Nurse midwives
• Clinical social workers
• Clinical psychologists
• Dietitians
• Nutritional professionals

Are there any MIPS eligible clinicians exceptions?

The following providers will be exempt from the MIPS negative payment adjustment in 2019 (which means they will not need to report for MIPS in 2017):

• Clinicians in their first year of Medicare Part B participation. In order to be classified as a newly enrolled Medicare eligible clinician, the clinician cannot have previously submitted claims in the previous calendar year either as an individual, an entity or as part of a group, regardless if they billed under a different tax number.
• Clinicians who have less than or equal to $30,000 in allowed Medicare Part B charges or less than or equal to 100 Medicare patients.
• Clinicians who are significantly participating in an Advanced APM as defined by CMS.
• Clinicians who bill 25 or fewer patient-facing encounters during 2017. CMS considers a patient-facing encounter as an instance in which the MIPS eligible clinician or group billed for services such as general office visits, outpatient visits, and surgical procedure codes under the Medicare Physician Fee Schedule. Patient facing encounters do not have to be face-to-face; CMS has included telemedicine under this definition of patient-facing.

Learn more about MIPS

As CMS begins to implement the Quality Payment Program we’ll be here to help you every step of the way. Find out more about MIPS and how the program will adjust Medicare payments for eligible clinicians by visiting our QPP resource center.