A Deep Dive into MIPS: Advancing Care Information

By Denise Scott, M.M. RN-BC, CMHP. Posted Mar 31, 2017 in Quality Reporting, MACRA/MIPS Program, Academy

You’ve been hearing a lot about MIPS lately. It seems that everywhere you look, someone has an eBook or a webinar that will reveal all of the secrets to successfully submitting for MIPS with one convenient, easy-to-digest piece of content. But is anyone really telling you anything you don’t already know?

Well, in this article, we dig quite a bit deeper into one specific category of MIPS; the Advancing Care Information category. This article is not for the faint of heart. You’ll want to put on some music, shut your door, and really think about how best to digest this information and put it to use with your clinicians.

If you aren’t quite ready for the deep dive, you can check out our Beginner’s Guide to MACRA. Like we mentioned above, this eBook is only an overview that is meant to get you started with understanding the program. Or, if you want to learn more about the Quality category of MIPS, read our previous blog.

MIPS Advancing Care Information (ACI) Category

Let’s start with the easy stuff. As everyone knows by now, CMS has released a new program called the Quality Payment Program. One of the tracks for successful completion of this program is the Merit-based Incentive Payment System (MIPS). And one of the categories of MIPS is the Advancing Care Information category, which replaces the Meaningful Use program you have become familiar with.


The Biggest Difference Between Meaningful Use & ACI

The biggest difference between the Meaningful Use EHR Incentive program and the ACI category is that performance does matter. In the past, physicians were used to meeting the Meaningful Use thresholds and not necessarily worrying about the actual performance of the measure. It didn’t matter how low the thresholds were as long as you met them. Now, your performance on certain ACI measures does matter.

Another change is that ACI attestation or reporting can be done at the group or individual level, not individual attestation only, as was the requirement for Meaningful Use reporting.

One other thing to note is that if you are reporting as an individual and you feel that the ACI measures aren’t relevant to your specialty, you can make a request to CMS to reassign the ACI percent of your score to the Quality category. If approved, you would have 85% of your MIPS total score attributed to your Quality score and the remaining 15% would be from Improvement Activities score.

Take a look at this infographic which gives you a breakdown of the categories weights for 2017.

Eligible Clinicians (ECs) in MIPS

The clinicians who are eligible to participate in MIPS has expanded from physicians only to include Nurse Practitioners, Physician Assistants, Certified Registered Nurse Anesthetists and Clinical Nurse Specialists.


Reporting Options (Individual or Group)

Ask yourself these questions: 

  1. Of your clinicians eligible for MIPS, who submits Medicare Part B claims to CMS as the primary billing clinician?
  2. Have all of your ECs reassigned their billing rights to one Tax ID or is there more than one Tax ID that will be reporting MIPS to CMS?


ECs can submit as individuals across all MIPS categories or as a group. A group is defined as two or more NPIs associated with a Tax ID (TIN). If you choose to report as a group, you will submit data on Advancing Care Information measures, as well as Improvement Activity and Quality measures, as a group. This means that aggregate data including, all clinician performance, will be submitted per measure on behalf of the group or TIN number. The group's fee schedule will be adjusted in 2019 based on that performance in 2017. If you report as a group in the ACI category, then you must report as a group for ALL categories. Keep that in mind as we look at the numbers associated with the Advancing Care Information category of MIPS.


Reporting Methods

In the past, you have attested to successfully complete your Meaningful Use requirements; now, you have several reporting methods to choose from.

  1. Attestation
  2. EHR
  3. Qualified Registry
  4. Qualified Clinical Data Registries (QCDR)
  5. CMS Web Interface*


If you have a vendor like Medisolv, who can submit all of your measures for each MIPS category using the EHR, this is our recommended method of reporting.

*Please note that if you choose to report using the CMS Web Interface then you must let CMS know that you will be using the Web Interface to report MIPS by June 30, 2017.


MIPS Reporting Requirements

We begin here by clarifying a few items around MIPS reporting generally. Remember that your performance with MIPS in 2017 impacts your 2019 Medicare reimbursement. The performance data period started on January 1, 2017 and continues until December 31, 2017. And finally, you must submit all measure categories to CMS by the March 31, 2018 deadline.

 Here is a recap of all the points available in MIPS broken down by category.

MIPS Category

Maximum Points

Percent of Composite (total) Score


60 or 70 points


Advancing Care Information

100 (up to 155 possible) points


Improvement Activities

40 points






ACI Reporting Requirements

The ACI reporting requirements are made up of two components, the Base Score and the Performance Score. What you need to remember is that you MUST report ALL BASE measures. If you do not report ALL BASE measures you will receive zero points in the ACI category, and you will not have the ability to report the ACI Performance measures.

If you report all Base measures, you will earn 50 points. From there, you can start racking up more points in this category by reporting on the Performance measures. This category also features bonus points. Your job is to get at least 100 ACI points, so you can get the full 25% ACI score as a part of the MIPS total score (see table above).

Base Score + Performance Score + Bonus Score = FINAL SCORE 



ACI Base Measures

This year, you may choose which ACI Base measure set you would like to report on. Here are your options.

ACI Objectives & Measures ACI Transition Objectives & Measures

2015 EHR Certification
MU Stage 3 Functionality

5 Base Measures
9 Performance Measures

2014 or 2015 EHR Certification
MU Stage 2 Functionality

4 Base Measures
7 Performance Measures


The column on the left requires you to have more advanced functionality in your EHR representing 2015 EHR certification. For 2017 reporting, Medisolv is suggesting that our clients use the 2017 ACI Transition measures.

Below is a chart showing you the Transition Base measures. Note the “Report Type” column. Also note the “Performance Score” column. CMS is not calculating performance of these Base measures - you just need to submit them to get the 50 Base measure points.

Objective Name

Measure Name

Report Type

Performance Score

Protect Patient
Health Information

Security Risk Analysis



Electronic Prescribing


Report Numerator & Denominator


Health Information Exchange

Send Summary of Care

Report Numerator & Denominator


Patient Electronic

Provide Patient

Report Numerator & Denominator





If all Base measures are submitted you receive
50 points


ACI Performance Measures

The Performance measures are the other half of the ACI category. Again, we are reviewing the 2017 Transition Performance measures here. In the chart below, you’ll notice that in the “Performance Score” column, you can earn points based on where your performance falls on the CMS decile ranking. In other words, how well you perform in comparison with other clinicians.

Objective Name

Measure Name

Report Type

Performance Score

Health Information

Send Summary of Care

Report Numerator & Denominator

Up to 20 points*

Patient Electronic

Provide Patient

Report Numerator & Denominator

Up to 20 points*

Patient Electronic

View, Download or
Transmit (VDT)

Report Numerator & Denominator

Up to 10 points*



Report Numerator & Denominator

Up to 10 points*

Patient Specific


Report Numerator & Denominator

Up to 10 points*

Secure Messaging

Secure Messaging  Report Numerator & Denominator   Up to 10 points*

Public Health

Immunization Registry Reporting 


Yes = 10 points
No = 0  
      Possibility of 90 points


* These points are based on the level of your performance in the decile ranking (i.e. how you rank in comparison with other clinicians that report for MIPS.)

You will also see that the Health Information Exchange and Provide Patient Access measures are in both the Base and Performance measure sets. If you report on at least one more Performance measure in this measure set, you could earn performance points for both the Health Information Exchange and Provide Patient Access measures. The decision to report one or both of these measures should depend on how good your performance is for those measures.


ACI Bonus Points

There is an opportunity for bonus points in the ACI category.


Bonus Points

Certain Improvement

10 points

Additional Public
Health Measure

5 points


If you choose to report the immunization registry measure and a second Public Health measure, such as reporting Syndromic Surveillance, you are eligible for the one-time 5-point bonus.


Tips for ACI 

I’ve compiled a list of tips to keep in mind while preparing for the ACI category submission of MIPS. 

  1. Report all Base measures to ensure at least 50 points in this category.
  2. Report at least one other Performance measure to get access to the Health Information Exchange and Provide Patient Access measure points that are in both the Base and Performance measure sets.
  3. Ensure that your measures in the Performance set are being documented correctly now, since they will be based on performance results.
  4. Everyone must start a 90-day reporting period no later than October 2, 2017.
  5. Performance matters!


Finally, choose your quality reporting vendor carefully and understand how they will support you in the calculation of your possible MIPS points in the Advancing Care Information category, as well as the Improvement Activities and Quality categories of MIPS. 

Surviving MIPS in Year 2

Preparing for MIPS reporting in 2018

This free educational webinar will help you understand who is eligible for the MIPS program and what’s required for successful completion. We will outline strategies that will help you prepare your providers for their best reporting year yet.

In this webinar, you will learn:

  1. About the changes made in the 2018 final rule for the Quality Payment Program;
  2. Reporting requirements for MIPS;
  3. How the final score is calculated;
  4. Best practices and resources for preparing your clinicians for a successful quality reporting year.

Surviving MIPS Year 2

, ,
Denise Scott, M.M. RN-BC, CMHP

Denise Scott, M.M. RN-BC, CMHP

Denise Scott, Director of Ambulatory Services, brings over 30 years in healthcare and over 15 years in HIT implementation, optimization, quality measurement and improvement in the ambulatory physician environment to Medisolv. Prior to joining Medisolv, Denise was a Director of Quality, Informatics and Clinical Integration for two large medical groups in Massachusetts and the former Manager, HIT Services at Masspro where she led a variety of HIT related projects. Denise is a subject matter expert on workflow redesign and Meaningful Use, and is board certified in Nursing Informatics.

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