MACRA, QPP, PAMA: Part 6 for Radiologists

8-Part Series for Radiologists:

Protecting your Medicare Revenue Stream in 2017-2018

Part 6: Preparing for MACRA and the QPP

Now that we have reviewed MACRA, the Quality Payment Program (QPP) and PAMA and their impact on radiology and imaging centers, Part 6 will cover the specific steps you should consider for the QPP.  Remember that if you qualify for QPP this year, and choose to do nothing, you are giving CMS your permission to cut your 2019 Medicare reimbursement by 4%.  We will cover the financial impact of that decision in Part 7.

Step #1:  Don't assume that QPP doesn't apply to you.

In the past month, I had a radiology administrator confidently tell me his radiologists were exempt.  But upon checking the online CMS tool, he found that they ARE qualified for QPP participation.

Remember, you can qualify as an individual or as a group.  So if you are a physician, check your NPI at  And if you are a practice administrator, check all the NPIs in your group.

Step #2:  Determine if you will qualify under the Merit-based Payment System (MIPS) or the Alternative Payment Model (APM).

There are specific criteria for the APM option under QPP.  The APM gives added Medicare payments to providers who demonstrate high-quality and cost-effective care.  An APM can apply to a specific clinical condition, a care episode, or a population.

Medicare also defines advanced APMs, which are a subset of the APM. The advanced APM provides an additional 5% on your Medicare fees.  To qualify, you must be part of a specially-designated program under Medicare such as a two-sided, at-risk shared payment program.  These typically include Accountable Care Organizations (ACO), federally designated patient-centered medical homes (PCMH) CMS-acknowledged programs in areas like oncology or end-stage renal disease.  If you think you are in one of these programs, but are not at some level of financial risk, you are still probably in a MIPS category rather than eligible under an APM.  You can visit the site to see the approved Advanced APMs for 2017.

There are minimum thresholds to meet in order to qualify as an advanced APM. If you assume you are in an APM, and later Medicare deems you were not, they will evaluate your performance for the year based on MIPS.

Step #3:  If you fall under MIPS, determine what data you will be submitting.

Unfortunately there is not a "one-size-fits-all" for radiologists.  The fact that you fall under MIPS will be because you meet the qualifying standards:

  1. Not in your first year of Medicare participation
  2. Bill $30,000 per year or more to Medicare
  3. Submit at least 100 of the qualifying CPT codes for the year, such as:
    1. Consultations
      1. Examples include a Nuclear Med specialist who sees patients for dosing radioactive iodine.
      2. A proceduralist who bills consultation or outpatient E&M codes for assessing patients.
    2. Interventions
      1. Certain ambulatory CPT codes that qualify under QPP:
        • 36555 Insertion of central venous device
        • 36556-61 Insertion of tunneled CVC w/port
        • 36568-69 PICC line placement
        • 37187-88 Percutaneous thrombectomy
        • 37230-31 Revascularization artery (such as arterial stents)
        • 37241 Vascular embolization
        • 62270-73 Lumbar punctures
        • 99201-205 Outpatient new visits
        • 99211-226 Established outpatient visit, Observation visits
        • Most other outpatient E&M Codes

Develop a strategy to determine what data you will submit for 2017.

  • Determine what "MIPS at my Pace" (See Part 3) looks like for you:
    • Full year of participation
    • Partial participation
    • Test data submission
    • No participation
  • Determine what data you will submit to get points in each of the three categories
    • Quality
    • Clinical Practice Improvement Activities
    • Advancing Care Information
  • Consider leveraging group data if part of a large radiology group or especially if part of a multi-specialty group practice
    • Remember to assess whether you may already be doing activities in 2017 for which you can get MIPS credit.

Remember that what you do in 2017 will determine your Medicare fees in 2019.  The last two parts will be available September 20 and 21st, respectively:

Part 7: The Financial Impact of Doing Nothing with QPP

Part 8: Frequently Asked Questions and Additional Resources


If you missed

Part 1: Introduction, CLICK HERE.

Part 2: Details of MACRA and the QPPCLICK HERE.

Part 3: How to Participate with QPP if you are a Radiologist Who QualifiesCLICK HERE.

Part 4: Overview of PAMA and the Appropriate Use Criteria (AUC) for Imaging. CLICK HERE.

Part 5: More on PAMA and the Appropriate Use Criteria for Advanced Diagnostic Imaging. CLICK HERE.

This 8-part series comes to you from Radius, LLC, a radiology services company and MedMorph LLC, healthcare IT consulting company.


Click on the diagram below to enlarge on your monitor:

5-step cycle for preparing for Medicare's QPP.

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