Health Language Blog

Maximizing MIPS Reimbursement

Posted on 06/08/16


MACRA Part 2

Maximizing MIPS Reimbursement

Laying the Right Foundation for Data Management

In the first edition of this two-part series covering MACRA and MIPS, we provided an overview of MIPS and its impact on terminology management and quality reporting. Part 2 will discuss why terminology management is critical to maximizing reimbursement under the new rule.

The stakes for quality and cost performance continue to rise. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is a prime example of why providers need to prioritize data access and management on a higher level than ever before.

Semantic interoperability—or the ability of two systems to exchange data in a meaningful way—remains a barrier to accurate data analytics and reporting. As pointed out in the first installment of this series, effective data normalization and terminology management is critical to accurately capturing data. Below I outline why terminology management must become a priority to maximize reimbursement within MACRA’s Merit-Based Incentive Payment System (MIPS).

Optimizing Clinical Documentation

Documentation must be correct, and as specific as possible, to fully capitalize on reimbursement under MIPS. If clinicians do not properly document patient encounters, EHR and analytics reports will miss identifying patients that belong to population cohorts required for reporting. For instance, if the right sinusitis codes or the right asthma codes are not selected, these patients will be missed when data is aggregated for quality measure reporting, leading to inaccurate results and potential payment reductions.

To ensure proper documentation, providers need their EHRs to have user-friendly interfaces that allow them to document using terms they know and use every day with other clinical and care staff. Back-end systems can then convert these terms to the proper ICD-10 and SNOMED codes. The user interface and back-end processing should coach the clinician to the most specific documentation codes possible. While the need for this kind of functionality may seem obvious, many certified EHR systems on the market today use faulty back-end logic for coding diagnoses and procedures. Most commonly, EHRs are connecting clinicians to non-specified codes that result in lower reimbursements and less accurate analytics.


Health Language offers an EHR “plug in” called Provider Friendly Terminology that allows providers to document conditions, diagnoses and procedures in language that aligns with their everyday language while coding to ICD-10 and SNOMED on the back-end with clinical guides to avoid selecting unspecified codes.



The new scoring system introduced by MIPS emphasizes the importance of promoting standards and interoperability. The reality is that Meaningful Use (MU) is not going away completely. It’s wrapped into the MIPS Advancing Care Information performance category with a new focus on achieving interoperability—an original MU goal that was not realized on the level the industry expected.

As provider organizations shift to value-based care, expand through consolidation and perform analytics, interoperability becomes increasingly paramount. Normalizing data inbound and outbound to achieve interoperability with other systems will require advanced terminology infrastructures and services. Even if providers are participating in alternative payment models such as ACOs instead of MIPS, interoperability is now a priority.

Patient Engagement

Implementation of the MIPS Advancing Care Information performance category is proposed to increase clinician and patient engagement. It’s a movement that has been underway for some time, and new requirements will advance patient access to data and promote use of patient-generated health data. Objectives include patient electronic access, coordination of care through patient engagement and health information exchange—all contributing to a provider’s performance within the new scoring system.

While provisions must allow patients to view online, download, and transmit health information, the question providers need to ask is: Does the patient understand the medical jargon seen in the problem lists and other sections?  If providers expect to engage patients successfully on a level that improves outcomes, patients need transparency into their care in a way that is understandable.

Terminology management strategies that translate medical jargon into consumer friendly terminologies will be critical to successfully navigating these opportunities. Patient-generated health data will also require the use of consumer friendly search descriptions. For instance, patients are more likely to search for nosebleed than epistaxis.


Time is of the essence as the first performance period for MIPS starts January 1, 2017. Providers need to initiate strategies now to lay the best foundation to support data capture. Terminology management that promotes optimal clinical documentation, interoperability and patient engagement is now a priority.


 Read Previous Blog Post                                                                   Read Next Blog Post


Topics: MIPS, MACRA, Reimbursement

About the Author

Dr. Brian Levy, MD is Vice President and Chief Medical Officer with Health Language, part of Wolters Kluwer Health. He holds an MD and BS from the University of Michigan. Go Blue!