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It’s go time for the Merit-based Incentive Payment System (MIPS), and just as we did last year, we are all looking for pain-free ways to avoid a penalty.

The Medicare Access and CHIP Reauthorization Act (MACRA) is designed to shift physician payment so that it rewards value and quality over volume via the creation of the Quality Payment Program (QPP). The QPP offers two pathways for reimbursement: MIPS and Advanced Alternative Payment Models (APM). (MIPS comprises the Physician-Value Based Payment Modifier (VBM), Physician Quality Reporting System (PQRS), and the Medicare EHR Incentive Program). Most dermatologists will not participate in the APM pathway; MIPS is the course for our specialty.


CMS recently published the 2018 rules for the 2020 fee schedule. Are you exempt? You may be if:

  • Your Medicare allowable income is less than $90,000, or
  • You have seen fewer than 200 unique Medicare patients

If you think you fit this bill, go to and enter your NPI number. A generated report will tell you if you’re exempt or in MIPS for 2018.


For measure 110 (influenza):

NOTE: Use of this G code is limited to the end of March 31, 2018, and from 10/1/18-12/31/18!

NUMERATOR NOTE: Denominator Exception(s) are determined at the time of the denominator eligible encounter during the current flu season.


Previous Receipt – Receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1).

Numerator Quality-Data Coding Options: Influenza Immunization Administered Performance Met: G8482: Influenza immunization administered or previously received


Influenza Immunization not Administered for Documented Reasons

Denominator Exception: G8483: Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons)


Influenza Immunization not Administered, Reason not Given

Performance Not Met: G8484: Influenza immunization was not administered, reason not given

**For measure 111 (pneumovax):

Numerator Quality-Data Coding Options:

Pneumococcal Vaccination Administered or Previously Received

Performance Met: CPT II 4040F: Pneumococcal vaccine administered or previously received


Pneumococcal Vaccination not Administered or Previously Received, Reason not Otherwise Specified Append a submission modifier (8P) to CPT Category II code 4040F to submit circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

Performance Not Met: 4040F with 8P: Pneumococcal vaccine was not administered or previously received, reason not otherwise specified

***For Measure 226 (tobacco use and cessation)

Numerator Quality-Data Coding Options:

Patient Screened for Tobacco Use, Identified as a Tobacco User or Tobacco Non-User

Performance Met: G9902: Patient screened for tobacco use AND identified as a tobacco user


Performance Met: G9903: Patient screened for tobacco use AND identified as a tobacco non-user

The Solution

If you are not exempt, you need to complete four measures on at least one patient in 2018 to avoid the -5 percent penalty in 2020. (Note: One measure that I recommend, influenza immunization, is not available to use until after October 1, 2018.)

If you report as a group, and have more than 14 practitioners, you will need to do five (rather than four) measures on at least one patient to avoid the penalty.

I have devised a way to avoid the MIPS penalty in 2020 without having to use a registry or even have an EHR. This method assumes you are on paper. However, you can also do it if you’re on an EHR, you do not have DataDerm (or another registry), and you are in a group of fewer than 15 clinicians.

You need to get 15 MIPS points to avoid the penalty, compared to only three points required last year. 

Any practice with fewer than 15 practitioners automatically gets a Small Practice Bonus of five points So, you only need an additional 10 points to avoid the penalty in 2020.

The only way to get points, given the above assumptions, is to submit quality measures via claims. I suggest submitting measure 130 (documentation of medications in chart with G code G8427)—as you did last year.

That leaves 3 more measures to submit on your claim (asterisks refer to appropriate G codes to submit on your claim, See box): 110 (influenza)*, 111 (Pneumovax)**, 226 (tobacco use)***.

One Day At a Time

As I did last year, I will be submitting these on more than one patient. My intent is to submit all four measures on all new Medicare patients in one day of seeing patients. That way, I spend no more than one day working to avoid the 5 percent penalty in 2020.

CMS has recently made their web interface available to submit data this year. You should be able to do one high-weighted improvement activity—and potentially submit it through the CMS web portal—and be exempt from the penalty without submitting any quality measures. Logging into their website ( is not as easy as you might think, so give it a try first. n

Mark D. Kaufmann, MD is an associate Clinical Professor of dermatology Dept of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.

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