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MACRA and The Quality Payment Program (QPP)


MACRA is the Medicare Access and CHIP Reauthorization Act of 2015. This law aims to shift the current mindset, rewarding value over volume and ending the flawed Sustainable Growth Rate (SGR). It is designed to encourage and reward providers for providing HIGH QUALITY care instead of just more of it.

The Quality Payment Program (QPP) - In October of 2016, CMS released the final rule for implementing the Quality Payment Program (QPP) as mandated by MACRA. The Quality Payment Program (QPP) improves Medicare by helping you focus on quality of care and offers two tracks to providers.

  • Advanced Alternative Payment Models (APMs) – Advanced APMs won’t apply to most independent chiropractors because they require 25% of payments to come from CMS or 20% of patients to be seen through an Advanced APM in 2017.

  • Merit-based Incentive Payment System (MIPS) – Eligible clinicians can earn a performance based increase in Medicare reimbursements. MIPS is divided into FOUR categories and combined to determine a composite performance score. These scores will be available publicly to help beneficiaries make more informed choices. The categories and percentage that each counts toward your total performance score are as follows:

  • Quality (60%) – This category replaces the Physician Quality Reporting System (PQRS). It appears that to report for this category, chiropractors will continue reporting the same two applicable measures reported under PQRS in the same manner. (Pain Assessment and Follow-Up and Functional Outcome Assessment)

  • Improvement Activities (15%) – New category. Focuses on care coordination, beneficiary engagement, and patient safety. Medicare lists 93 total activities to choose from. 14 of them have a high activity weighting. Most chiropractors will report on four either through an EHR or approved registry such as

  • Advancing Care Information (25%) – Replaces “Meaningful Use”. You may not need to submit Advancing Care Information if the measures do not apply to you. There are two measure sets. Both have five measures that are required for the base score, but you can submit up to nine measures for additional credit. The five base score measures are:

  • Security Risk Analysis

  • e-Prescribing

  • Provide Patient Access

  • Send Summary of Care

  • Request/Accept Summary of Care

If the measures don’t apply you will not report that measure and it would not be included in your score calculations.

  • Cost – Replaces the “Value-Based Modifier” but not included in the 2017 score. This information comes from the dollar amount on claims forms. Provide lower cost care than your peers and receive a higher score in 2018. *Requires no action by the provider.


You CAN participate as an individual if you have a single NPI tied to a single tax ID, or as a group if you share a common tax ID with other providers.

Many providers do not have to participate in this new program in 2017. This will include about 85% of Chiropractors.

• If you are in your first year of practice, or

  • you don’t see over 100 Medicare (CMS) beneficiaries in 2017 OR

• you bill Medicare less than $30,000 in allowed charges, participation is optional.

**To be eligible for MIPS incentives or penalties you must not qualify for exemption.

Click the following link and enter your National Provider Identifier (NPI) to see if you’re included in MIPS:


  • You can choose to start reporting anytime between January 1 and October 2, 2017

  • No matter when you choose to start, your performance data needs to be submitted by March 31, 2018.

  • The first payment adjustments based on performance go into effect on January 1, 2019.


Some providers may want to avoid penalties while others could actually see a benefit from full participation and going for the incentives.

If you choose the MIPS path of the Quality Payment Program, you have three options.

  • Test: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.

  • Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment and may even earn the max adjustment.

  • Full: If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment.



In 2017, more than 85% of Chiropractors may be exempt from the program. However, clinicians who are not included in MIPS right now, may still opt to voluntarily submit data individually to Medicare.


  • For learning purposes

  • To obtain feedback on quality measures

  • To prepare in the highly likely event that MIPS is expanded in the future

  • Administrative burden of reporting is not that high for providers who have already been participating in Meaningful Use and PQRS.

  • Your performance rating will become publicly available alongside similar providers at sites such as Medicare’s Physician Compare

If you choose to participate voluntarily, quality data can be submitted via claim forms in the same manner as PQRS. For PQRS, chiropractors were required to report on two quality measures. 1) Quality Measure #131: Pain Assessment and Follow Up and, 2) Quality Measure #182: Functional Outcome Assessment and Follow Up. For these two measures, there are 12 possible codes, though it is likely that you will only use 5 or 6 on a regular basis.


Documenting for Quality Measures

Documenting for Quality Measure codes is easy. You simply need to include in your daily record a statement of what was done on that visit that justifies the use of the reporting codes you are submitting.

Example: Pain was assessed on today’s visit using the VAS scale and was recorded as an 8. Our follow-up plan is to re-administer the VAS scale on the next visit to assess the patient’s pain level. This could be stated in the daily record as follows: G8730 – Pain was assessed on today’s visit and was positive as reflected above. Pain will be reassessed on the patient’s next visit.

In the Document Plus system, these statements can be set up as templates so that you don’t find yourself having to completely type in the information for each code every time. If you need assistance in setting this up for your office please contact Melanie at 888-588-6648 to schedule an appointment.

Submitting Codes for Quality Measures

  • Submit one code for each measure for each eligible Medicare patient visit

**Eligible patient >18 years old AND visit includes 98940, 98941, or 98942**

  • Assign a “$0.00” charge for each quality measure code. If your clearinghouse will not allow for a zero charge, assign a $0.01 charge and adjust later.

  • QM codes are to be submitted on the same date of service as the 9894x code

  • Make sure QM codes appear on the same claim form as the 9894x code

  • NPI number should be the same for QM codes and the 9894x code


**Clinicians who submit data voluntarily will not be subject to a positive or negative payment adjustment.


This program is the beginning of a new way to get paid for healthcare. Medicare already has plans to expand the program and private payers may someday follow. Even if you choose not to participate in 2017 because you don’t have to, you’ll want to be kept in the loop as things unfold. Know that, at Document Plus, we are working hard to deliver the most up-to-date information to your inbox. However, it doesn’t just stop there. We are available to answer any questions you may have. Please do not hesitate to contact us.

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