Daily Practice

MIPS: Hospital/University Billing

Latest in MIPS

July 2018 - CMS released final 2017 feedback and information on the 2019 payment adjustment. Have questions? Contact us!

Learn about the QOPI Reporting Registry for data submission and see the full 2018 quality measure list!

Reporting Structure 

The “Hospital/University Billing” model is where the eligible physicians have assigned their National Provider Identifier (NPI) to an academic university, community hospital or large multi-specialty group practice Taxpayer Identification Number (TIN). There is a strong likelihood that the hospital is billing both of the professional component (PC) and technical component (TC) of a single service together. 

In this billing model, we expect that individuals will report MIPS data as part of a large, multispecialty group. Be sure to confirm this with your administration. In this setting, most radiation oncologists may not have direct involvement in hospital decisions regarding MIPS participation; however, it is important to ask questions of your administration and understand what the hospital or university is doing to satisfy the MIPS requirements. Additionally, you can contribute to your group’s MIPS reporting with radiation oncology-specific programs such as RO-ILS: Radiation Oncology Incident Learning System and Accreditation Program for Excellence (APEx).

If you are told by your administration that you must report individually, please see the Physician or Group Billing Webpage for detailed information about radiation oncology specific MIPS reporting. For a high-level overview of MIPS, visit the 2017 MIPS Webpage.

2017 MIPS is based on three performance categories: Improvement Activities, Quality and Advancing Care Information.

Improvement Activities

Checklist_IAThe "Improvement Activities" (IA) performance category is a new program in which eligible clinicians attest to completing activities identified as improving clinical practice or care delivery likely to result in improved outcomes. CMS has identified over 90 approved activities for 2017, most of which can be found on CMS' QPP website. Participation in either or both of two ASTRO programs, RO-ILS and APEx, can help satisfy this performance category so be sure to notify your hospital administration of participation! In 2017, improvement activities only need to be completed for a minimum of 90-consecutive days so being the contracting process today!

RO-ILS: Radiation Oncology IncidentLearning System®, sponsored by ASTRO and AAPM, is a part of Clarity PSO, a federally listed patient safety organization. A medium weighted activity within the “Improvement Activity” (IA) Performance Category is “Participation in an AHRQ-listed patient safety organization” (Activity ID = IA_PSPA_1). Participating in RO-ILS automatically satisfies the “Test: Improvement Activities” option within “Pick Your Pace,” so 2017 RO-ILS participants will likely avoid a negative adjustment in 2019. There is no fee to participate in RO-ILS, but the facility must contract with Clarity PSO so start the contracting process now. Join the more than 275 RO-ILS facilities today and check off your minimum 2017 MIPS requirement! 

While only attestation of activity completion is necessary for 2017 reporting, be sure to maintain documentation to demonstrate consistent and meaningful engagement within the period for which you are attesting. In the event of an audit, documentation must be presented.

For this particular activity, CMS suggests “documentation from an AHRQ-listed patient safety organization (PSO) confirming the eligible clinician or group's participation with the PSO.” Therefore, upon request, Clarity PSO will send a Letter of Participation stating that your practice or facility is actively participating in RO-ILS during the reporting period. Please email radoncsupport@claritygrp.com to request a RO-ILS Letter of Participation. Letters will be sent later in the year.

Additionally, you can use RO-ILS towards fulfilling the Part IV Physician Quality Improvement (PQI) Maintenance of Certification (MOC) requirements established by the American Board of Radiology. This meets an additional medium-weighted improvement activity (Activity ID = IA_PSPA_2)! 

ASTRO’s Accreditation Program for Excellence (APEx) focuses on a culture of quality and safety, as well as patient-centered care. Evidence indicators required for APEx accreditation map to 16 improvement activities. One of the 16 activities is participation in MOC Part IV, which can be accomplished with the APEx MOC template. The self-assessment component of the program can satisfy all the requirements for the Improvement Activities performance category. 

In the event of an audit, proof of completion of each activity needs to be maintained. The APEx MIPS IA Table includes CMS recommended documentation as well as the mapped APEx Standard. 


Star_QualityThe “Quality” Performance Category is a new iteration of the Physician Quality Reporting System (PQRS). Just as in previous years of PQRS, CMS will provide an online option for groups with more than or equal to 25 eligible clinicians. We envision the majority of academic universities and community hospitals will elect to utilize the CMS Web Interface, previously known as the PQRS Reporting Option (GPRO) Web Interface, to report quality data to CMS.

To report via the CMS Web Interface or administer the CAHPS survey, groups must have registered by June 30, 2017. The CAHPS survey is no longer mandatory for groups of any size. These two options require a 12-month performance period. Please note that groups previously registered for the 2016 PQRS GPRO Web Interface will be automatically registered for the 2017 MIPS CMS Web Interface. If the group would like to participate through another data submissino option, they had to "cancel" the registration before June 30, 2017.

The 15 preselected measures in the CMS Web Interface target high-cost chronic conditions, preventive care, and patient safety. Measures can be found on the CMS QPP website within the “Quality Measure Specifications Supporting Documents”. Groups utilizing the CMS Web Interface will need to report on all 15 measures for the first 248 consecutively ranked and assigned Medicare beneficiaries. If the pool of eligible assigned beneficiaries is less than 248, then the group would report on 100 percent of the assigned beneficiaries.

If your hospital or university decides not to report via the CMS Web Interface and will thereby submit independent measures, you may want to propose reporting on one or more of the following measures from the radiation oncology measures set.

Radiation Oncology Measures Set
Quality ID Measure High Priority Measure?
(if Yes, Type)
eMeasure? Measure Specifications
102 Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
Yes Registry
143 Pain Intensity Quantified
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.
(Patient Experience)
Yes Registry
144 Plan of Care for Pain
Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
(Patient Experience)
No Registry
156 Radiation Dose Limits to Normal Tissues
Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3-D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3-D conformal radiation for a minimum of two tissues.
(Patient Safety)
No Registry

As a reference, the complete list of 2017 MIPS Quality measures, can be found CMS’s QPP Website.

Advancing Care Information 

Computer_ACIThe “Advancing Care Information” (ACI) performance category is a new iteration of the EHR Incentive (Meaningful Use) program. CMS will consider eligible physicians who furnish more than 75 percent of their covered professional services in an on-campus hospital (POS 22) exempt from the ACI category. CMS makes this determination based on claims data for a period prior to the performance year. The "hospital-based" designation can be found on the QPP MIPS Participation Status Tool. For hospital-based physicians, you will not need to request an exemption.

Last Updated September 12, 2017


 Please check back regularly to see the latest updates. ASTRO is continually updating this site to reflect new and/or changing information from the federal government and other sources.

As always, each radiation oncology practice and its eligible clinicians are encouraged to review primary materials (statutes, regulations, agency interpretive guidance, etc.) and seek appropriate legal or other professional guidance for a comprehensive understanding of their obligations. The information on this website should not be construed as legal, coding or other professional advice, and ASTRO assumes no liability for the information contained herein.

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