Managing the Medicare Merit-Based Incentive Payment System (MIPS) can be a challenge for retina specialists. With certain fundamental core knowledge, however, the program can be successfully implemented into practices with or without electronic health records (EHRs). This article outlines some of the basics.

Automatic Exemptions

It is doubtful that most retina practices would qualify, but a practice is automatically exempt from any penalties if it receives less than $90,000 in Medicare Part B allowables or sees fewer than 200 Medicare Part B patients in a calendar year.

Reporting Periods

Quality Measures (QM)

• Via EHR registries or manual data entry: Report over the course of the entire calendar year for 60% of all qualifying patients, regardless of their insurance.
• The Centers for Medicare and Medicaid Services (CMS) will award partial credit on QMs reported on fewer than 60% of patients or less than a full year (one point).
• Via claims: Report over the course of the entire calendar year for 60% of all qualifying Medicare Part B patients only. Although this may seem enticing, the downside is that there are fewer measures and higher benchmarks, so the curve is more challenging.
• Remember: If the claim is denied, the MIPS QM will be denied as well.
• There is also a quality improvement score worth up to 10% added into a practice’s quality score.

Advancing Care Information (ACI)

• The reporting period is 90 consecutive days.
• These data require the use of Certified EHR Technology (CEHRT).
• Only patient encounters captured by CEHRT can be reported for ACI, meaning practices will not be downgraded for group reporting if only some of the clinicians are using CEHRT.

For ACI-based measures, physicians must submit all four (2014 CEHRT) or five (2015 CEHRT) base measures to receive credit. These measures require a minimum of one patient in the numerator.

The American Academy of Ophthalmology (AAO) received accommodation on health information exchange measures from CMS, and clinicians with less than 100 referrals or transitions of care in the performance period can be excluded.


The 5% MIPS penalty that will take effect in 2020 will apply to all Medicare payments, including anti-VEGF drugs. Retina specialists must report a minimum of one IA, clinical cluster, or six QMs to avoid the penalty.


How? Report six QMs, a clinical cluster, or an IA to achieve 15 points on the final MIPS score.


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Improvement Activities (IAs)

• The reporting period is 90 consecutive days.
• Reporting more IAs than the requirement may increase the potential for a practice audit.

Cluster Categories (New)

Rather than reporting six QMs, practices without EHRs may use AAO’s Intelligent Research in Sight (IRIS) Registry to report 60% of patients, regardless of their insurance, for a full year on one of the following options:

1. Age-Related Macular Degeneration

• Counseling on antioxidant supplements
• Dilated macular examination

2. Retina Care

• Retinal detachment, return to OR within 90 days
• Retinal detachment, visual acuity improvement within 90 days

Cost: The New Category as of 2018

Weighted at 10% of a practice’s MIPS score for the 2018 performance year, CMS will evaluate two measures based on claims data:

1. Medicare spending per beneficiary

2. Total per capita cost per attributed beneficiary

How can retina specialists prepare? Go to and download your Quality Resource Use Report. If the report doesn’t seem accurate to you, contact the CMS QualityNet help desk at (866) 288-8912 or email

Good News: Small-Practice Accommodations

CMS defines a small practice as one with 15 or fewer eligible clinicians.

• If reporting less than the entire calendar year or less than 60% of patients, small practices earn three points rather than one.
• Double credit is given for each IA.
• A five-point bonus is added to MIPS final score.
• These physicians receive small-practice hardship accommodations under ACI.

Sue Vicchrilli, COT, OCS
• Director of Coding and Reimbursement at the American Academy of Ophthalmology
• Financial disclosure: None acknowledged