MACRAnyms

MACRAnyms

Get familiar with all the acronyms used in the new world of MACRA. Let us help you wade through the alphabet soup with this acronym guide.

Acronym

What It Stands For

Definition

Acronym

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MACRA

What It Stands For

:

Medicare Access and CHIP Reauthorization Act

Definition

:

The Medicare Access and CHIP Reauthorization Act (MACRA) is landmark legislation that makes three important changes to how Medicare pays physicians who provide care to Medicare beneficiaries. These changes include: repealing the sustainable growth rate (SGR) formula for determining Medicare payments for health care providers’ services; creating a new framework for rewarding health care providers for giving better care; and combining existing quality reporting programs into one new system.

See also: Sustainable Growth Rate (SGR), Medicare, Children’s Health Insurance Program (CHIP)

Acronym

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CMS

What It Stands For

:
Centers for Medicare & Medicaid Services

Definition

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Part of the Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) manages the administration of Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Health Insurance Marketplace.

See also: Medicare, Medicaid, Children's Health Insurance Program (CHIP), Health and Human Services (HHS)

Acronym

:
HHS

What It Stands For

:
Heath and Human Services

Definition

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Health and Human Services (HHS) is the department of the U.S. federal government whose mission is to enhance and protect the health and well-being of all Americans. HHS has 11 operating divisions that include the Centers for Medicare & Medicaid Services (CMS).

See also: Physician-focused Payment Model Technical Advisory Committee (PTAC)

Acronym

:

CHIP

What It Stands For

:

Children's Health Insurance Program

Definition

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The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

Acronym

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What It Stands For

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Medicare

Definition

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Medicare is a federally administered health insurance program for people 65 or older, people under 65 with certain disabilities, and people of all ages with end-stage renal disease (ESRD).

Acronym

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What It Stands For

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Medicaid

Definition

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Medicaid is a national health insurance program for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Unlike Medicare, Medicaid is administered at the state level.

Acronym

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SGR

What It Stands For

:

Sustainable Growth Rate

Definition

:

The sustainable growth rate (SGR) was the target set by the Centers for Medicare & Medicaid Services (CMS) to control the growth in aggregate Medicare expenditures for physicians' services. It was repealed as part of MACRA and is no longer used in the Medicare program.

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA)

Acronym

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RBRVS

What It Stands For

:

Resource-based Relative Value Scale

Definition

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The resource-based relative value scale (RBRVS) is the list of services and relative value units (RVUs) from which Medicare physician payment is determined. Services are assigned a relative value that is adjusted by a geographic price cost index (GPCI) and multiplied by a conversion factor. 

Acronym

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EC

What It Stands For

:
Eligible Clinician

Definition

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An eligible clinician (EC) is an individual physician or health care provider who is eligible to participate in, or is subject to, mandatory participation in a Medicare or Medicaid program. For the purposes of the Merit-based Incentive Payment System (MIPS), an EC for years one to two of the program includes physicians, physician assistant, nurse practitioner, clinical nurse specialist, and certified registered nurse anesthetists.

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS)

Acronym

:

MIPS

What It Stands For

:

Merit-based Incentive Payment System

Definition

:

The Merit-based Incentive Payment System (MIPS) is one of two new payment tracks established by MACRA that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program. MIPS consolidates these Medicare initiatives into one single program based on: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology.

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Physician Quality Reporting System (PQRS), Advancing Care Information (ACI), Value-based Payment Modifier (VBPM), Clinical Practice Improvement Activities (CPIA), Meaningful Use (MU)

Acronym

:

APM

What It Stands For

:

Alternative Payment Model

Definition

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An Alternative Payment Model (APM) is one of two new payment tracks established by MACRA. It involves a new approach to paying for medical care through Medicare that incentivizes quality and value. As defined by the law, APMs include: the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center Model, Medicare Shared Savings Program (MSSP), demonstration under the Health Care Quality Demonstration Program, or a demonstration required by federal law.

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Medicare Shared Savings Program (MSSP), Advanced Alternative Payment Model (AAPM)

Acronym

:
AAPM

What It Stands For

:
Advanced Alternative Payment Model

Definition

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An Advanced Alternative Payment Model (AAPM) is an APM that has met the statutory APM requirements, as well as three additional criteria: (1) the APM must require participants to use certified EHR technology, (2) the APM must provide payment for covered services based on quality measures comparable to those in the quality performance category under MIPS, (3) the APM must either require APM entities to bear risk for monetary losses of more than a nominal amount under the APM, or be a Medical Home Model expanded under section 1115A(c) of the Act. The proposed rule identifies five AAPMs for the first performance period: Comprehensive ESRD Care (CEC) through a large-dialysis organization arrangement, Comprehensive Primary Care Plus (CPC+), Medicare Shared Savings Program (MSSP) Tracks 2 and 3, and Next Generation ACO Model.

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Medicare Shared Savings Program (MSSP), Alternative Payment Model (AAPM), Nominal Risk, Comprehensive Primary Care Plus (CPC+), Alternative Payment Model (APM) Entity, Next Generation Accountable Care Organization (ACO)

Acronym

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MU

What It Stands For

:

Meaningful Use

Definition

:

Established in 2011, the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs were established to encourage eligible professionals and eligible hospitals to adopt, implement, upgrade (AIU), and demonstrate meaningful use (MU) of certified EHR technology. The last year to begin participation and receive incentive payments in the Medicare program was 2014. The final year to begin participation under the Medicaid program is 2016.

 

See also: Certified Electronic Health Record Technology (CEHRT)

Acronym

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ACI

What It Stands For

:
Advancing Care Information

Definition

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Advancing Care Information (ACI) is a performance category under the Merit-based Incentive Payment System (MIPS) requiring the meaningful use of electronic health record (EHR) technology.

See also: Merit-based Incentive Payment System (MIPS)

Acronym

:

CEHRT

What It Stands For

:

Certified Electronic Health Record

Definition

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The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have established standards and other criteria for structured data that electronic health records (EHRs) must use in order to qualify for the EHR Incentive Program. To get an incentive payment, you must use an EHR that is certified specifically for the EHR Incentive Programs. Certified EHR technology gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.

 

See also: Meaningful Use (MU)

Acronym

:

PQRS

What It Stands For

:

Physician Quality Reporting System

Definition

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The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. Performance reports are available through the Physician Feedback reports and Quality and Resource Use Report (QRUR).

 

See also: Value-based Payment Modifier (VBPM), Quality and Resource Use Report (QRUR)

Acronym

:

VBPM

What It Stands For

:

Value-based Payment Modifier

Definition

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A budget-neutral Value-based Payment Modifier (VBPM) provides for differential payment under the Medicare physician fee schedule (PFS) to a physician or group of physicians based upon the quality of care compared to the cost of care furnished to Medicare fee-for-service (FFS) beneficiaries during a performance period. Also called the Value Modifier (VM), the VBPM is separate from the payment adjustment and incentives under the Physician Quality Reporting System (PQRS). Performance information is available in the Quality and Resource Use Report (QRUR).

 

See also: Physician Quality Reporting System (PQRS), Quality and Resource Use Report (QRUR)

Acronym

:

CPIA

What It Stands For

:

Clinical Practice Improvement Activities

Definition

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Clinical practice improvement activities (CPIA) is a performance category under the Merit-based Incentive Payment System (MIPS). CPIAs are identified as improving clinical practice or care delivery that, when effectively executed, are likely to result in improved outcomes. CPIA categories include expanded practice access; population management; care coordination; beneficiary engagement; patient safety and practice assessment; and participation in an Alternative Payment Model (APM). A certified patient-centered medical home (PCMH) will automatically receive full credit in the CPIA performance category of the Merit-Based Incentive Payment System (MIPS).

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), Alternative Payment Model (APM), Patient-centered Medical Home (PCMH)

Acronym

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PCMH

What It Stands For

:

Patient-centered Medical Home

Definition

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A patient-centered medical home (PCMH) is a model or philosophy of primary care that is patient centered, comprehensive, team based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. All certified PCMHs will receive full credit in the clinical practice improvement activities (CPIA) performance category of the Merit-based Incentive Payment System (MIPS).

 

See also: Clinical Practice Improvement Activities (CPIA), URAC, Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), National Committee for Quality Assurance (NCQA)

Acronym

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ACO

What It Stands For

:

Accountable Care Organization

Definition

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Accountable care organizations (ACOs) are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated, high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

Acronym

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QP

What It Stands For

:

Qualifying Alternative Payment Model (APM) Participant

Definition

:

A qualifying Alternative Payment Model (APM) participant (QP) is an eligible clinician (EC) who receives a percent of their payments or sees a percent of their patients through an Advanced APM entity. A qualifying participant (QP) is eligible to receive the 5 percent lump sum bonus and is excluded from the Merit-based Payment System (MIPS) payment adjustments. The percent of payments required increases as the program progresses. Initially, a provider must receive at least 25 percent of their Medicare payments or see 20 percent of patients through the Advanced APM entity. Beginning in 2021, a provider can meet the threshold through a combination of Medicare and other non-Medicare payer arrangements.

 

See also: Eligible Clinician (EC), Merit-based Incentive Payment System (MIPS), Attributed Beneficiary, Attribution-Eligible Beneficiary, Threshold Score, Advanced Alternative Payment Model (AAPM), Advanced Alternative Payment Model (AAPM) Entity

Acronym

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Partial QP

What It Stands For

:
Partial Qualifying Alternative Payment Model (APM) Participant

Definition

:

A partial qualifying Alternative Payment Model (APM) participant (QP) is an eligible clinician (EC) who participates in an Advanced APM, but has not met the payment or patient threshold to be considered a qualifying APM participant (QP). A partial QP is not eligible to receive the 5 percent lump sum bonus and can elect to participate in the Merit-based Incentive Payment System (MIPS). In payment years 2019 and 2020, to be considered a partial QP, an EC must receive 20 percent of payments or see 10 percent of patients through an Advanced APM entity.

 

See also: Eligible Clinician (EC), Merit-based Incentive Payment System (MIPS), Attributed Beneficiary, Attribution-eligible Beneficiary, Threshold Score, Qualifying Alternative Payment Model (APM) Participant, Alternative Payment Model, Advanced Alternative Payment Model (AAPM), Advanced Alternative Payment Model (AAPM) Entity

Acronym

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MSSP

What It Stands For

:

Medicare Shared Savings Program

Definition

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Congress created the Medicare Shared Savings Program (MSSP) to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the MSSP by creating or participating in an accountable care organization (ACO). The MSSP will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary. The Centers for Medicare & Medicaid Services (CMS) has designated MSSP tracks 2 and 3 as Advanced Alternative Payment Models (AAPMs).

 

See also: Advanced Alternative Payment Model (AAPM)

Acronym

:

CPC

What It Stands For

:

Comprehensive Primary Care

Definition

:

The Comprehensive Primary Care (CPC) initiative is a four-year multi-payer initiative designed to strengthen primary care. The Centers for Medicare & Medicaid Services (CMS) has collaborated with commercial and state health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “comprehensive” primary care functions. These five functions are: (1) risk-stratified care management; (2) access and continuity; (3) planned care for chronic conditions and preventive care; (4) patient and caregiver engagement; and (5) coordination of care across the medical neighborhood. The initiative is testing whether provisions of these functions at each practice site — supported by multi-payer payment reform, the continuous use of data to guide improvement, and meaningful use (MU) of health information technology — can achieve improved care, better health for populations, lower costs, and can inform future Medicare and Medicaid policy.

 

See also: Center for Medicare and Medicaid Innovation (CMMI)

Acronym

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CPC+

What It Stands For

:

Comprehensive Primary Care Plus

Definition

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The Comprehensive Primary Care Plus (CPC+) is a five-year advanced primary care medical home model that aims to strengthen primary care through regionally-based multipayer reform and care delivery transformation. CPC+ begins in 2017, and will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the U.S. CPC+ will provide practices with a learning system, as well as actionable patient-level cost and utilization data feedback to guide decision making. Practices in both tracks will make changes in the way they deliver care, centered on key Comprehensive Primary Care (CPC) functions. The Centers for Medicare & Medicaid Services (CMS) has designated CPC+ as an Advanced Alternative Payment Model (AAPM).

 

See also: Advanced Alternative Payment Model (AAPM), Center for Medicare and Medicaid Innovation (CMMI)

Acronym

:

CMMI

What It Stands For

:

Center for Medicare and Medicaid Innovation

Definition

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The Center for Medicare and Medicaid Innovation (CMMI) was created as part of the Affordable Care Act (ACA) to test payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care.

Acronym

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QRUR

What It Stands For

:

Quality and Resource Use Report

Definition

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The Quality and Resource Use Report (QRUR) provides information on a tax identification number’s (TIN) performance on all available quality and cost measures used to calculate the 2016 Value Modifier (VM). Annual QRURs will provide information on how the TINs’ quality and cost performance will affect their physicians’ Medicare physician fee schedule (PFS) payments.

 

See also: Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), CMS Enterprise Portal, Enterprise Identity Management (EIDM)

Acronym

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TCPi

What It Stands For

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Transforming Clinical Practice Initiative

Definition

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The Transforming Clinical Practice Initiative (TCPi) is designed to help clinicians achieve large-scale health transformation. The initiative is designed to support more than 140,000 clinician practices over the next four years in sharing, adapting, and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act (ACA) to strengthen the quality of patient care and spend health care dollars more wisely.

Acronym

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PTN

What It Stands For

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Practice Transformation Network

Definition

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Practice Transformation Networks (PTNs) are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core competencies specific to practice transformation. 

 

See also: Transforming Clinical Practice Initiative (TCPi)

Acronym

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SAN

What It Stands For

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Support and Alignment Network

Definition

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Support and Alignment Networks (SANs) provide a system for workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts.

Acronym

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LAN

What It Stands For

:

Learning and Action Network

Definition

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The goal of the Learning and Action Network (LAN) is to align private payers and the Centers for Medicare & Medicaid Services (CMS) to move payment from traditional fee-for-service (FFS) methods to FFS-linked to quality and Alternative Payment Models (APMs). Specifically, the LAN goals are that in 2016, at least 30 percent of U.S. health care payments are linked to quality and value through APMs. In 2018, at least 50 percent of U.S. health care payments are so linked. These payment reforms are expected to demonstrate better outcomes and lower costs for patients.

 

See also: Centers for Medicare & Medicaid (CMS), Alternative Payment Model (APM)

Acronym

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PPACA

What It Stands For

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Patient Protection and Affordable Care Act

Definition

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Signed into law by President Barack Obama in 2010, the Patient Protection and Affordable Care Act (PPACA), or ACA, puts in place comprehensive health insurance reforms. Reforms include: expanded coverage, holding insurance companies accountable, lowering health care costs, and guaranteeing more choices in health care.

Acronym

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PAMA

What It Stands For

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Protecting Access to Medicare Act

Definition

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Signed into law in 2014, the Protecting Access to Medicare Act (PAMA) prevented a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on April 1, 2014. This law maintained the 0.5 percent update for such services that applied from January 1, 2014, through March 31, 2014, for the period April 1, 2014, through December 31, 2014. It also provides for a zero percent update to the 2015 Medicare physician fee schedule (MPFS) through March 31, 2015.

AcronymWhat It Stands For
Definition
Acronym:

CPS

What It Stands For:

Composite Performance Score

Definition:

The composite performance score (CPS) is the aggregate of an eligible clinician's (EC’s) scores in the four performance categories (quality, resource use, advancing care information, clinical practice improvement activities). The CPS will be compared to a Merit-based Incentive Payment System (MIPS) performance threshold. An EC’s payment adjustment will be determined based on his/her CPS.

 

See also: Merit-based Incentive Payment System (MIPS), Eligible Clinician (EC), Payment Adjustment Factor

Acronym:

PECOS

What It Stands For:

Medicare Provider Enrollment, Chain, and Ownership System

Definition:

The Medicare Provider Enrollment, Chain, and Ownership System (PECOS) is an online system that allows providers to electronically submit an initial Medicare enrollment application, update and manage enrollment information, track enrollment, manage reassignment of benefits, and withdraw from the Medicare Program. The Centers for Medicare & Medicaid Services (CMS) will use the information in PECOS to verify an eligible clinician's (EC’s) specialty and determine if the provider is considered newly enrolled for the purposes of the Merit-based Incentive Payment System (MIPS). CMS will also use the contact information provided in the EC’s PECOS record for communicating when MIPS performance feedback is available.

 

See also: Merit-based Incentive Payment System (MIPS)

Acronym:  What It Stands For:

Advanced Alternative Payment Model (AAPM) Entity

Definition:

An AAPM entity is an entity that participates in an Alternative Payment Model (APM) that the Centers for Medicare & Medicaid Services (CMS) has determined to be an Advanced APM.

 

See also: Advanced Alternative Payment Model (AAPM)  

Acronym:  What It Stands For:

Alternative Payment Model (APM) Entity

Definition:

An APM entity is an entity that participates in an Advanced Alternative Payment Model (AAPM) through a contract with a payer.

 

See also: Alternative Payment Model (APM)

Acronym:  What It Stands For:

Attributed Beneficiary

Definition:

A beneficiary attributed to the Advanced Alternative Payment Model (AAPM) is on the latest available list of attributed beneficiaries during the Qualifying APM Participant (QP) performance period. Beneficiary attribution is based on each APM's respective attribution rules.

 

See also: Advanced Alternative Payment Model (AAPM), Qualifying Alternative Payment Model (APM) Participant (QP), Partial Qualifying Alternative Payment Model (APM) Participant (Partial QP), Attribution-Eligible Beneficiary

Acronym:  What It Stands For:

Attribution-Eligible Beneficiary

Definition:

In order to be attributed to an Advanced Alternative Payment Model (AAPM) entity, a beneficiary must be one who: is not enrolled in Medicare Advantage or a Medicare cost plan; does not have Medicare as a secondary payer; is enrolled in both Medicare Parts A and B; is at least 18 years of age; is a U.S. resident; has a minimum of one claim for evaluation and management (E/M) services by an eligible clinician or group of eligible clinicians within an APM entity during the Qualifying APM participant (QP) performance period.

 

See also: Advanced Alternative Payment Model (AAPM), Qualifying Alternative Payment Model (APM) Participant (QP), Alternative Payment Model (APM) Entity, Attributed Beneficiary

Acronym:  What It Stands For:

High-Priority Measure

Definition:

A high-priority measure is a quality measure within one of the following categories: outcome, appropriate use, patient safety, efficiency, patient experience, or care coordination. 

Acronym:  What It Stands For:

Low-volume Threshold

Definition:

A low-volume threshold is set by the Centers for Medicare & Medicaid Services. Any clinician falling below would be excluded from the Merit-based Incentive Payment System (MIPS) payment adjustments. As proposed, to fall below the low-volume threshold, an eligible clinician must have billing charges of less than or equal to $10,000 and provide services to 100 or fewer Medicare Part B beneficiaries during the performance period.

 

See also: Merit-based Incentive Payment System (MIPS), Medicare Part B

Acronym:  What It Stands For:

Measure Benchmark

Definition:

A measure benchmark is the level of performance on measures a Merit-Based Incentive Payment System (MIPS) eligible clinician (EC) will be assessed.

 

See also: Merit-Based Incentive Payment System (MIPS)

Acronym:  What It Stands For:

Medicaid Alternative Payment Model (APM)

Definition:

A Medicaid Alternative Payment Model (APM) is a payment arrangement under title XIX that meets the criteria to be an Other Payer Advanced Alternative Payment Model (AAPM).

 

See also: Alternative Payment Model (APM), Advanced Alternative Payment Model (AAPM), Other Payer Advanced Alternative Payment Model

Acronym:  What It Stands For:

New Medicare-enrolled Merit-based Incentive Payment System (MIPS) Eligible Clinician (EC)

Definition:

A new Medicare-enrolled Merit-based Incentive Payment System (MIPS) eligible clinician (EC) is a professional who first becomes a Medicare-enrolled eligible clinician within the Provider Enrollment, Chain, and Ownership System (PECOS) during the performance period and who has not previously submitted claims as a Medicare-enrolled EC either as an individual, an entity, or part of a physician group or under a different billing number or tax identifier.

 

See also: Medicare Provider Enrollment, Chain, and Ownership System (PECOS)

Acronym:  What It Stands For:

Non-patient Facing Merit-based Incentive Payment System (MIPS) Eligible Clinician (EC)

Definition:

A non-patient facing Merit-based Incentive Payment System (MIPS) eligible clinician (EC) is an EC or group that bills 25 or fewer patient-facing encounters during a performance period. A patient-facing encounter is coded as such when the clinician or group bills for services, such as general office visits, outpatient visits, and surgical procedure codes. Telehealth will also be considered patient-facing. The Centers for Medicare & Medicaid Services (CMS) will publish a list of patient-facing encounter codes.

Acronym:  What It Stands For:

Other Payer Advanced Alternative Payment Model

Definition:

An other payer Advanced Alternative Payment Model (AAPMs) includes payment arrangements under any payer other than traditional Medicare. Medicare Advantage and other Medicare-funded private plans are categorized as a payer other than traditional Medicare. To be considered an other payer AAPM, the arrangement must meet the following criteria: use certified EHR technology; quality measures comparable to measures under the Merit-based Incentive Payment System (MIPS) quality performance category; and the APM entity must bear more than nominal financial risk or, for beneficiaries under title XIX, is a medical home in a Medicaid Medical Home Model meeting the criteria to Medical Home Models expanded under section 1115A(c) of the Act. The other payer AAPM option will be available beginning in performance year 2021.

 

See also: Advanced Alternative Payment Model (AAPM), Merit-based Incentive Payment System (MIPS), Alternative Payment Model Entity (APM), Medicare Part B, Medicare Part C

Acronym:  What It Stands For:

Performance Category Score

Definition:

The performance category score is an assessment of each eligible clinician (EC) or group's performance on the applicable measures and activities for a performance category (quality, resource use, advancing care information, clinical practice improvement activities) in the Merit-based Incentive Payment System (MIPS). The performance category scores are used in the calculation of composite performance score (CPS).

 

See also: Eligible Clinician (EC), Composite Performance Score (CPS)

Acronym:  What It Stands For:

Small Practice

Definition:

A small practice is defined by the MACRA law as a practice with 15 or fewer clinicians.   

Acronym:  What It Stands For:

Threshold Score

Definition:

The threshold score is a percentage value compared to the qualifying Advanced Alternative Payment Model (AAPM) payment and patient thresholds. An APM entity's threshold score will determine the qualifying APM participant (QP) status for the payment year.

 

See Also: Advanced Alternative Payment Model (AAPM), Qualifying Alternative Payment Model (APM) Participant (QP), Partial Qualifying Alternative Payment Model (APM) Participant (Partial QP)

Acronym:  What It Stands For:

Topped-out Measures

Definition:

A measure may be considered topped out if the measure performance is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made.

Acronym:  What It Stands For:

Cross-cutting Measures

Definition:

A measure that is broadly applicable across multiple specialties (i.e. a measure that is not specialty-specific) is considered a cross-cutting measure. An example of a cross-cutting measure is NQF 0419 - Documentation of Current Medications in the Medical Record.

Acronym:  What It Stands For:

Nominal Risk

Definition:

Contained in the MACRA law, Advanced Alternative Payment Models (AAPMs) must assume nominal risk; or, risk of an amount that is lower than optimal, but substantial enough to drive performance.

 

See also: Advanced Alternative Payment Model (AAPM), Marginal Risk, Minimum Loss Rate (MLR), Total Potential Risk

Acronym:  What It Stands For:

Marginal Risk

Definition:

Marginal risk refers to the percentage of the amount by which actual expenditures exceed expected expenditures for which an Alternative Payment Model (APM) entity would be liable under the APM. For example, an entity with a marginal risk rate of 30% that exceeded expected expenditures by $100,000 could be liable for $30,000 (100,000 X 30% = 30,000).

 

See also: Nominal Risk, Alternative Payment Model (APM) Entity

Acronym: MLRWhat It Stands For:

Minimum Loss Rate

Definition:

A minimum loss rate (MLR) is the percentage of the actual expenditures that may exceed expected expenditures without triggering financial risk. For an example, risk would not be triggered for an entity with expected expenditures of $1,000,000 and a minimum loss rate of 4% if their actual expenditures did not exceed the expected expenditures by more than $40,000 (1,000,000 X 4% = 40,000).

 

See also: Nominal Risk, Alternative Payment Model (APM) Entity

Acronym:  What It Stands For:

Total Potential Risk

Definition:

Total potential risk is the maximum potential payment for which an Alternative Payment Model (APM) entity could be liable under the APM. For example, an entity with a total potential risk of 4% and expected expenditures of $1,000,000 would not be liable for more than $40,000 (1,000,000 X 4% = 40,000).

 

See also: Nominal Risk, Alternative Payment Model (APM) Entity

Acronym:  What It Stands For:

Payment Adjustment Factor

Definition:

A payment adjustment factor is the percentage adjustment applied to a Merit-based Incentive Payment System (MIPS) eligible clinician's (EC’s) Medicare Part B payments, resulting in differential payments. The adjustment factor will be applied based on a linear sliding scale. An EC with a composite performance score (CPS) of zero will receive a neutral payment adjustment factor. This is also referred to as the MIPS adjustment factor.

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Eligible Clinician (EC), Composite Performance Score (CPS)

Acronym:  What It Stands For:

All-cause Hospital Readmissions

Definition:

All-cause hospital readmissions is the measure of readmission rate of beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission within 30 days of discharge. This measure is a claims-based outcome measure included in the Quality performance category of the Merit-based Incentive Program (MIPS).

 

See also: Merit-based Incentive Program (MIPS)

Acronym:

MSPB

What It Stands For:

Medicare Spending Per Beneficiary

Definition:

The Medicare spending per beneficiary (MSPB) is a measure of all Medicare Part A and B payments during an episode spanning three days prior to an index (inpatient prospective payment system (IPPS) hospital admission through 30 days post discharge. This is a claims-based measure included in the Resource Use performance category of the Merit-based Incentive Payment System (MIPS).

 

See also: Merit-based Incentive Program (MIPS), Medicare Part A, Medicare Part B

Acronym:

 

What It Stands For:

Total Cost Per Capita

Definition:

Total cost per capita is a measure of overall efficiency of care provided to attributed beneficiaries. This is a claims-based measure included in the Resource Use performance category in the Merit-based Incentive Payment System (MIPS).

 

See also: Merit-based Incentive Program (MIPS)

Acronym:

 

What It Stands For:

Episode-based Measure

Definition:

An episode-based measure includes Medicare Part A and B payments, and related to a triggering condition or procedure. Clinical and treatment episode-based measures are designed to evaluate resource utilization of specific procedures and conditions that are costly and prevalent in the Medicare population. Episode-based measures are included in the Resource Use performance category of the Merit-based Incentive Payment System (MIPS).

 

See also: Merit-based Incentive Program (MIPS), Medicare Part A, Medicare Part B

Acronym:

 

What It Stands For:

Base Score

Definition:

The base score makes up 50 percent of the Advancing Care Information (ACI) performance category score. An eligible clinician must report a numerator and denominator for all measures specified in the ACI category.

 

See also: Advancing Care Information (ACI), Eligible Clinician (EC)

Acronym:

 

What It Stands For:

Performance Score (Advancing Care Information)

Definition:

The performance score allows an eligible clinician (EC) to achieve additional percentage points above the base score in the Advancing Care Information (ACI) performance category. An EC's performance on measures for patient electronic access, coordination of care through patient engagement, and health information exchange can contribute an additional 50 percentage points to the clinician's base score.

 

See also: Base Score, Advancing Care Information (ACI), Eligible Clinician (EC)

Acronym:

 

What It Stands For:

Virtual Groups

Definition:

Virtual groups are an option allowing individual Merit-based Incentive Payment System (MIPS) eligible clinicians (ECs) or groups with 10 or fewer eligible clinicians to elect to report as a group in MIPS. The virtual group option will not be available during the first performance period, which is proposed to be 2017.

 

See also: Merit-based Incentive Program (MIPS), Eligible Clinician (EC)

Acronym:

CAHPS

What It Stands For:

Consumer Assessment of Healthcare Providers and Systems

Definition:

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a survey tool used to ask patients to report their experiences with the health care system. The survey can be administered through a Centers for Medicare & Medicaid Services (CMS)-approved survey vendor.

Acronym:

PTAC

What It Stands For:

Physician-focused Payment Model Technical Advisory Committee

Definition:

The Physician-Focused Payment Model Technical Advisory Committee (PTAC) was established under the Medicare Access and Chip Reauthorization Act (MACRA) and will provide comments and recommendations to the Secretary of Health and Human Services (HHS) on physician payment models, such as alternative payment models.

 

See also: Physician-Focused Payment Model (PFPM), Medicare Access and CHIP Reauthorization Act (MACRA), Alternative Payment Model (APM), Health and Human Services (HHS)

Acronym:

PFPM

What It Stands For:

Physician-focused Payment Model

Definition:

A physician-focused payment models (PFPM) is an alternative payment model (APM) where Medicare is a payer, and includes physician group practices or individual physicians as Alternative Payment Model (APM) entities and targets the quality and costs of physician services. The Physician-Focused Payment Model Technical Advisory Committee will review proposed PFPMs.

 

See also: Physician-Focused Payment Model Technical Advisory Committee (PTAC), Alternative Payment Model (APM)

Acronym:

EIDM

What It Stands For:

Enterprise Identity Management

Definition:

Enterprise Identity Management is a system used by the Centers for Medicare & Medicaid Services (CMS) for identity verification, access management, password reset, etc. An EIDM account is required to login into the CMS Enterprise Portal.

 

See also: CMS Enterprise Portal

Acronym:  What It Stands For:

CMS Enterprise Portal

Definition:

The CMS Enterprise Portal is an online portal maintained by the Centers for Medicare & Medicaid Services (CMS) to provide access to various CMS systems and databases. An Enterprise Identity Management (EIDM) user account is required to login to the portal. This portal allows users to access their Quality and Resource Use Reports (QRUR), as well as elect group reporting for the Physician Quality Reporting System (PQRS).

 

See also: Enterprise Identity Management (EIDM), Centers for Medicare & Medicaid (CMS), Quality and Resource Use Report (QRUR), Physician Quality Reporting System (PQRS)

Acronym:  What It Stands For:

URAC

Definition:

URAC is an independent organization offering patient-centered medical home (PCMH) accreditation. Practices receiving PCMH recognition from URAC will automatically receive full credit in the Clinical Practice Improvement Activities (CPIA) performance category.

 

See also: Patient-Centered Medical Home (PCMH), Clinical Practice Improvement Activities (CPIA)

Acronym:

TJC

What It Stands For:

The Joint Commission

Definition:

The Joint Commission (TJC) is an independent, non-profit organization offering patient-centered medical home (PCMH) accreditation. Practices receiving PCMH recognition from TJC will automatically receive full credit in the Clinical Practice Improvement Activities (CPIA) performance category.

 

See also: Patient-centered Medical Home (PCMH), Clinical Practice Improvement Activities (CPIA)

Acronym:

NCQA

What It Stands For:

National Committee for Quality Assurance

Definition:

The National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization offering patient-centered medical home (PCMH) recognition. Practices receiving PCMH recognition from the NCQA will automatically receive full credit in the Clinical Practice Improvement Activities (CPIA) performance category.

 

See also: Patient-centered Medical Home (PCMH), Clinical Practice Improvement Activities (CPIA)

Acronym:

AAAHC

What It Stands For:

Accreditation Association for Ambulatory Health Care

Definition:

The Accreditation Association for Ambulatory Health Care (AAAHC) is a private, non-profit organization offering patient-centered medical home (PCMH) recognition. Practices receiving PCMH recognition from the NCQA will automatically receive full credit in the Clinical Practice Improvement Activities (CPIA) performance category.

 

See also: Patient-centered Medical Home (PCMH), Clinical Practice Improvement Activities (CPIA)

Acronym:

 

What It Stands For:

Medicare Part A

Definition:

Medicare Part A is an original (traditional) Medicare plan covering services such as hospital care, skilled nursing facility care, nursing home care, hospice, and home health services. Medicare Part A is managed by the Centers for Medicare & Medicaid Services.

Acronym:

 

What It Stands For:

Medicare Part B

Definition:

Medicare Part B an original (traditional) Medicare plan covering services such as lab tests, surgeries, office visits, and supplies that are considered medically necessary. Medicare Part B is managed by the Centers for Medicare & Medicaid Services.

Acronym:

 

What It Stands For:

Medicare Part C

Definition:

Medicare Part C plans (also known as Medicare Advantage) are offered by private insurance plans to beneficiaries who are enrolled in original Medicare. Medicare Advantage plans typically offer additional coverage such as vision, dental, hearing, and can include prescription drug coverage.

Acronym:

 

What It Stands For:

Medicare Part D

Definition:

Medicare Part D offers a prescription drug coverage option, which is available to original (traditional) Medicare plans.

Acronym:

 

What It Stands For:

Exceptional Performance

Definition:

Eligible clinicians (ECs) who meet or exceed the additional performance threshold have achieved exceptional performance. These ECs will be eligible for an additional positive payment adjustment under the Merit-Based Incentive Payment System (MIPS). The maximum exceptional performance payment adjustment is 10 percent and will be made on a sliding scale based on performance. The adjustment falls outside of the budget neutrality requirements of the Merit-Based Incentive Payment System (MIPS) adjustments and is only available from 2019 to 2024.

 

See also: Additional Performance Threshold

Acronym:

 

What It Stands For:

Additional Performance Threshold

Definition:

Established at the composite performance score (CPS) level, the additional performance threshold is the additional level of performance at which an eligible clinician (EC) may achieve and receive an additional positive payment adjustment under the Merit-Based Incentive Payment System (MIPS).

 

See also: Composite Performance Score (CPS), Exceptional Performance

Acronym:

CF

What It Stands For:

Conversion Factor

Definition:

The conversion factor (CF) is the dollar amount updated on an annual basis used in determining payment rates for a particular service. The CF is multiplied by the relative value units (RVUs) of a service, resulting in the payment rate for the service.

 

See also: Resource-based Relative Value Scale (RBRVS)

Acronym:

PFS

What It Stands For:

Physician Fee Schedule

Definition:

The physician fee schedule (PFS) includes the list of Medicare covered services and payment rates for those services. The list is updated annually.

Acronym:

 

What It Stands For:

Next Generation Accountable Care Organization (ACO)

Definition:

An accountable care organization (ACO) model builds on the Pioneer model by setting predictable financial targets, and offering greater opportunities to coordinate care. The goal of the Next Generation ACO model is to test whether strong financial incentives for the ACO, coupled with better patient engagement and care management, can improve health outcomes and lower expenditures for beneficiaries. The Centers for Medicare & Medicaid Services (CMS) has designated Next Generation ACO as an Advanced Alternative Payment Model (AAPM).

 

See also: Advanced Alternative Payment Model (AAPM)

Acronym:

 

What It Stands For:

Budget Neutrality

Definition:

Remaining budget neutral is a requirement of the Medicare Access and CHIP Reauthorization Act (MACRA) that ensures the amount of the positive payment adjustments do not exceed that of the negative payment adjustments.

Acronym:

 

What It Stands For:

Alternative Payment Model (APM) Scoring Standard

Definition:

Merit-based Incentive Payment System (MIPS) eligible clinicians (ECs) participating in certain types of Alternative Payment Models (APM) will be scored using a different standard than the MIPS scoring standard. Under the APM scoring standard, the weights of the performance categories may be different than the generally applicable weights for MIPS-eligible clinicians. A MIPS composite performance score (CPS) will be aggregated at the APM entity level based on scores on MIPS-eligible clinicians in the APM entity.

 

See also: Alternative Payment Model (APM), Alternative Payment Model (APM) Entity, Composite Performance Score (CPS), Merit-based Incentive Payment System (MIPS), Eligible Clinician (EC)

Acronym:

HPSA

What It Stands For:

Health Professional Shortage Area

Definition:

Health professional shortage areas (HPSAs) are designated by the Human Resources and Services Administration (HRSA) as having shortages of primary care, dental, or mental health providers. HPSAs may be geographic, demographic, or institutional.

Acronym:

 

What It Stands For:

Merit-based Incentive Payment System (MIPS) Performance Category

Definition:

As defined by Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS) contains four performance categories: quality, resource use, clinical practice improvement activities, and advancing care information (meaningful use of EHR technology). An eligible clinician's (EC’s) performance in each category will be weighted and contribute to a composite performance score (CPS). The weights of the categories will change as the program progresses. Initially, quality will be weighted at 50 percent, resource use at 10 percent, clinical practice improvement activities at 15, and advancing care information at 25 percent.

 

See also: Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), Composite Performance Score (CPS), Clinical Practice Improvement Activities (CPIA), Advancing Care Information (ACI), Eligible Clinician (EC), Performance Category Score