MACRA & MIPS Webinar Recording 

Download MACRA/MIPS FAQ Document



FAQ’s from MACRA & MIPS Webinar on December 15, 2016

How do you collect data after the date of service?
If this question is in reference to collecting Quality Measures for MIPS, we will be introducing a new MIPS quality measures editor to do exactly that. Once it is released, we will conduct a webinar and training sessions on how it functions.


For MU 2016 when we attest I know we can attest to 90 consecutive days and I correct if we wanted to attest August 24 to November 22?
This is a very unique situation. Most users will attest to a 90-day consecutive period or one full year. I am unsure how CMS will address data for a time frame between those 2 amounts.


Right now we cannot accept electronic referrals through TRAKnet. When will that change to meet the base requirements?
For the transition year of 2017, TRAKnet is still utilizing the 2014 certified version. By the end of 2017, we will be certified for 2018 to accept referrals.


I have a 2017 exemption for MU because of my internet. How does this work with MIPS?
As of now, CMS has not mentioned exemptions for participation in MIPS. We will continue to monitor any changes in the coming months.


What is the deadline for submitting PQRS?
The deadline to submit your PQRS data to the registry is 1/31/17


What documentation is needed from the primary for the a1c.  Does it have to be a printed lab and scanned in patient’s chart?
Yes. In order to meet the requirement for this measure, you must have documentation of the a1c value, not just the word of the patient


Do you have to use the G codes for both the claim reporting AND if you use the registry?
Yes. There are specific codes to use whether reporting PQRS measures via claims or registry.


Is that 100 total Medicare of 100 individual patients?
If referencing the low-volume threshold for exclusion for MIPS, the 100 patients is in reference to Medicare patients.


Do you have to have TRAKnet Cloud version to perform the 3 and 4 of Advancing Care model?
You do not need to have the cloud version of TRAKnet to perform base measures 3 & 4 for the Advancing Care Information portion of MIPS.


Will TRAKnet supply the CPT codes for MIPS?
Yes. TRAKnet is working with our developers to incorporate not only the new quality measures editor, but the HCPCS codes that are associated with the measures.

What is a care plan? Example please
Advance directives are designed to respect patient’s autonomy and determine his/her wishes about future life- sustaining medical treatment if unable to indicate wishes. Key interventions and treatment decisions to include in advance directives are: resuscitation procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation.


How soon will the editor tutorials begin?
As soon as the new quality measures editor is available we will provide training immediately.


Do you submit MIPS through a registry?
MIPS can be submitted via claims or a registry

Is Meaningful Use being replaced in 2017 as well?
The Advancing Care Information portion of MIPS is replacing Meaningful Use in 2017


Is attestation open to do for 2016?
I am unaware of attestation is available yet. Most likely the attestation site will open after 1/1/17.


I have tried to attest for MU for 2016. EHR website has dates for attesting 1/1/2016 to 12/31/2016. It won’t let you change dates for the 90-day period. Do we have to wait until this is fixed to attest?
Most likely after 1/1/17 this will be adjusted by CMS and you can attest for your consecutive 90-day period.


How will we be able to achieve sending and receiving transition of care with TRAKnet?
We are currently developing this functionality for use in 2018 when this is required. For 2017, you only need to send a transition of care, not receive one.


It would be extremely helpful if you could give us a practical walk through from the time we start with a patient to when we chart and what will we be submitting to the registry.
Our upcoming webinars will do just that.


Is an APM the same as am ACO?
Yes. An ACO is one of the APM’s.


We are signed up for MedExpress and HAVE been submitting PRQS through the claims method.  Is this a problem?
That should not present a problem. You will upload your registry report to MedxPress at the end of the calendar year.


Is MIPS only for Medicare patients?
While you can choose Medicare patients if you choose to submit your quality measures through the claims method, if choosing registry, you will use all your patients.


Will these quality measures have to show up on the CCD?
No. This is not part of the information required on the CCD-A


If I am a full member of an ACO, do I need to be doing any of this or does the ACO do this for me?
Most DPM’s can’t be participating member of an APM. I would check with your ACO.


For 2016, I collected data for registry throughout the year. Now that it is 90 days do I need to collect new data for just 90 days?
While Meaningful Use is for a consecutive 90-day period, your PQRS data needs to be submitted for a full calendar year.


If a patient isn’t sure if their PCP ordered an HBA1c, can you report it as undone or do you need to call the PCP to see if it was done?
I would contact the PCP since there needs to be documentation (lab results).


What about the MedXpress through TRAKnet update ready?
The integration with MedXpress for the submission of specialized data is currently within TRAKnet. The PQRS integration will be completed by the end of the calendar year.


How do we find out about the registration prescription monitoring programs?
I would contact your state association or state licensing agency for guidance on this.


Does pain assessment and current meds have to be reported on every E&M visit for the patient as what has been done in the past?
Yes. Those quality measures need to be reported on every E&M visit.


Are these measures reported once per reporting period per individual patient?
The benchmarks for the calculations of the quality measures has not been released by CMS. In order to remain neutral, if you reported the measures once, one only one patient, you will not incur the penalty for 2019.


Are we going to be able to load the measure in our note the same way we do with the PQRS templates now?
We are anticipate releasing a new quality measures editor to track your measures and will not be done via templates.


Is it true that for the TEST PACE, we then just need ONE quality measure, one time to meet that MIPS testing?
Yes. In order to remain neutral and not receive a penalty or positive adjustment, you can report on one quality measure for one patient.


Can MedxPress report PQRS measures for an ACO member?
Please contact MedxPress for clarification on this matter.


For a1c if we only report above 9 or not done, won’t we be penalized for not reporting on enough patients? Low percentage?
If you are only interested in avoiding a negative payment adjustment, reporting on one quality measure, on one patient is enough.


Is the 90-day period quarterly or any 90 days?
Any consecutive 90-day period.


What if the patient refuses BP reading?
You can report that, but you will not have performed it. There is a difference between performing and reporting. Performing the measure will be what is needed for a modest incentive, not just reporting.


For the low-volume threshold, in a group, is it each provider, or a group that brings in less than $30K?
If billing under one TIN, it will be looked at as a group.


With either doing claims or registry–do we still use the same coding?  Or how do we document to get the quality credit?
Yes. The same HCPCS codes are used for claims or registry.


So, for minimum requirement (test pace), we have to do one Quality measure OR 1 Improvement activity OR 4 Advanced care information measures, not all 3 categories?
Yes, that is correct.


I currently include PQRS on my claims. I have Med Express as a registry. Am I doing this correctly?
You can still submit the registry report to MedxPress for submission of your PQRS data by 1/31/17.


Do we record the measure on the encounter and not send on the claim to insurance? Will TRAKnet then put it in a report to send to the registry?
If submitting your quality measures via registry, the HCPCS codes do not need to appear on the claim. TRAKnet will have a new MIPS quality measures report in order for you to submit/export to the registry.


In 2017, will Quality Measures still only be reported on an EM CPT?
Depending on the measures chosen, each measure has different requirements.


What do you mean by some data?
If you report, one quality measure, one improvement activity or the 4 base measures under advancing care information, that is all that is required to avoid a penalty.


So I think you all are saying that if my diabetic pts only come in for routine foot care that has no E&M it will not count against me for quality measures since they will not be in the denominator of which I must have 50% in the numerator-if so that’s very good!
The quality measures for diabetic patients do include at risk foot care codes, 11719, 11720, 11721 as eligible CPT codes.


I am a member of an ACO. I have never submitted PQRS, the ACO has done this for me.  Are the quality measures submitted for me via the ACO like PQRS was?
I would check with your ACO to confirm.


My data is spread out over 360 days. Is that okay?
If you customize the dates in the Meaningful Use report, you can check any 90-day period to check your data for completeness.


Can we use Medxpress for PQRS this year? TRAKnet updated to transfer data to them?
Yes. You will have the ability to upload your PQRS data to MedxPress for 2016 and 2017.


How do we register for MedxPress registry?
Please contact them at


Once we get HBA1C results how do you say that you received the results? Is there a code? Do I make and addendum? How do I show this?
By scanning the lab report and then utilizing the proper choice under the a1c measure, you will be documenting the receipt of the information.


Can we claim an exclusion to Health Info exchange if there is no referral or transition of care?
While CMS has allowed for an exclusion for meaningful use in 2016, they have stated that there will likely be no exclusion under MIPS for this measure.


Under advanced care is there still an exemption for eRx for those who write less than 100 Rx?
No. At this time, both e-rx and the measure for risk analysis do not hold any weight and must be done in order to receive the base score. There is no exclusion on the amount of e-rx’s you send.


What is documentation for smoking cessation? Can this be done by a DPM?
Yes. This requires a quick, less than three minute discussion with your patient and documentation that the patient stops using tobacco, not just smoking.


Will TRAKnet have a report for the Advanced Care Information measures?
Yes. You will see a new Advancing Care Information Report in 2017


Is faxing considered electronically submitting?
For the purposes of the 2017 transition year, it is permitted.


For ACI view, download and transmit, and for patient access are we required to use the TRAKnet portal or can this be done through HealthVault?
This is done through HealthVault.


Can pneumococcal vaccination be self-reported?
There is no terminology in the measure that states the measure can’t be self-reported by the patient.


What is an example of electronically summary transmission?  Would it be sending my podiatry notes to a PCP?
If you generate a CCD-A and fax to the PCP, you would satisfy this requirement.


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