Quality Payment Program

Overview of MACRA and the Quality Payment Program

The Medicare Access and CHIP Reauthorization Act created the Quality Payment Program. According to the Centers for Medicare and Medicaid Services, the foundation of the Quality Payment Program is high value patient centered care supported by meaningful feedback and continuous improvement. The program was designed to move Medicare away from volume based reimbursement toward quality and value based reimbursement.

Medical coding plays a central role in this system. Quality reporting depends on accurate diagnosis and procedure coding. Reimbursement depends on accurate documentation. For CMCC professionals, understanding the relationship between coding, quality reporting, and reimbursement is essential.

Two Pathways Under the Quality Payment Program

1 Merit Based Incentive Payment System MIPS

2 Advanced Alternative Payment Models APMs

MIPS evaluates individual clinician performance and adjusts payments based on performance scores. Advanced APMs provide payment models that reward care coordination and shared financial accountability.

MIPS Performance Categories

Quality

Cost

Promoting Interoperability

Improvement Activities

Graph 1 Example Distribution of MIPS Categories

Source https://qpp.cms.gov/mips/overview

Graph 2 Conceptual Payment Impact

Source https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms

Medical Coding Consultants must connect documentation, coding accuracy, quality reporting, and reimbursement strategy. Quality measures depend on coded data. Cost measures depend on coded claims. Inaccurate coding can lower performance scores and reduce Medicare payments.

Coders are no longer isolated technical staff. They are essential contributors to revenue cycle management and compliance oversight.

Medical Coding Consultant Responsibilities in MIPS

Ensure diagnosis accuracy for quality measure reporting

Support compliance with documentation requirements

Assist with audit preparedness

Monitor performance feedback reports

Educate clinicians on documentation improvement

Official Reference Websites

Quality Payment Program https://qpp.cms.gov/

MIPS Overview https://qpp.cms.gov/mips/overview

MACRA Overview https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms

APM

An Alternative Payment Model (APM) is a way of paying doctors and healthcare providers based on the quality of care and cost control, not just the number of services provided.

Under APMs, clinicians can earn extra incentive payments if they provide high-quality and cost-effective care. In some models, they may also share financial risk if costs are too high. This means there can be both rewards and penalties.

APMs can focus on:

• A specific disease (like diabetes or heart failure)

• A particular treatment episode (like a surgery)

• Or a group of patients (a population)

Examples of APMs:

• Pay-for-Performance – Providers are paid more for meeting quality targets.

• Bundled Payments – One combined payment for all services related to a treatment or surgery.

• Shared Savings Programs – Providers share in the savings if they reduce healthcare costs while maintaining quality.

• Accountable Care Organizations (ACOs) – Groups of providers work together to improve care and reduce costs.

• Patient-Centered Medical Homes – Focus on coordinated, continuous care led by a primary care provider.

In simple words:

APM = Better care + Cost control = Extra rewards (with some financial risk).