Complying with MACRA

Helping You Comply with MACRA in Today’s Health Care Environment

Background: Signed into law in 2015, the Medicare Accessibility and CHIP Reauthorization Act (MACRA) MACRA introduces several changes to the current physician reimbursement framework. Physicians who participate in a traditional Medicare fee-for-service will earn a performance-based payment adjustment to their Medicare payment through the Merit-Based Incentive Payment System (MIPS).

The performance period for MIPS begins January 1, 2017 and the first payment adjustments will be applied in 2019.

For future deadlines and submission dates, refer to

IAC Accreditation Can Fulfill Portions of MIPS Performance Measures

Physicians that decide to participate in MIPS will earn a Medicare payment adjustment based on practice-specific quality data for providing high-quality, efficient care through success in four performance categories. The IAC Quality Improvement (QI) Tool and IAC Maintenance of Certification (MOC) activity are options that may be used to satisfy the Improvement Activity component.

I. Quality [Replaces the Physician Quality Reporting System (PQRS)]
II. Advancing Care Information (Replaces the Medicare EHR Incentive Program, also known as Meaningful Use)
III. Improvement Activities (Often referred to as Clinical Practice Improvement Activities (CPIA) (New category)
In this new performance category for 2017, clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety.
The IAC QI Self-Assessment Tool or the IAC QI MOC Activity satisfy the requirements of this category.
IV. Cost (Replaces Value-Based Modifier)


CMS Reporting of MIPS Improvement Activity ID



MIPS Data Submission Options

For both individual and group reporting, attestation is one method of data submission to CMS for the Improvement Activities category. Individual physicians or groups may submit data in multiple mechanisms as outlined in the Federal Register, however the same identifier and same submission mechanism must be used per category. QI meeting minutes must document that 90 days of the quality improvement methods/processes/activities implemented have occurred to receive credit for this activity. IAC serves as the repository for this data and information on attestation requirements are detailed below as referenced below from the CMS MIPS Improvements Activities Fact Sheet:

Submitting Improvement Activities

Eligible clinicians may submit their improvement activities by attestation via the CMS Quality Payment Program website, a qualified clinical data registry, a qualified registry, or, when possible, from their electronic health record system. Groups of 25 or more may choose to use the CMS Web Interface. Eligible clinicians and groups only need to attest via the Quality Payment Program website that they completed the improvement activities they selected or should work with their vendor to determine the best way to submit their activities via a qualified clinical data registry (QCDR), a qualified registry, or their electronic health record system.

Eligible clinicians are encouraged to retain documentation for 6 years as required by the CMS document retention policy. 

Reporting Criteria

  • You must attest by indicating “Yes” to each activity that meets the 90-day requirement (activities that you performed for at least 90 consecutive days during the current performance period).
  • You may report activities using a qualified registry, via certified EHR Technology), qualified clinical data registry (QCDR), the CMS Web Interface (for groups of 25 or more), or via attestation. These intermediaries will need to certify that you performed the activities as indicated.
  • You can choose to attest to the set of activities that are most meaningful to your practice since there are no subcategory reporting requirements. That is, you don’t have to select activities in each subcategory or select activities from a certain number of subcategories.
  • If you choose to participate in MIPS via a QCDR, you must select and achieve each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR.

The Improvement Activity performance category counts for 15% of your MIPS final score, unless you or your group is subject to the APM Scoring Standard. If the APM Scoring standard applies, the weight of the improvement activity score toward the final score depends on the APM.

More information about the MIPS data submission methods are outlined in the Federal Register. (42 CFR) pages 312 and 313 at the following link:

The IAC is committed to assisting participating facilities to ensure clinicians within accredited facilities earn credit under MIPS for their quality efforts. For further assistance from the IAC related to satisfying components of quality initiatives through IAC accreditation, contact

IAC Resources

CMS Resources