CMS Discloses Requirements for Positive Payments Under MIPS in 2021

CMS Discloses Requirements for Positive Payments Under MIPS in 2021

A final rule released for public inspection Nov. 2 finalizes policy for Year 3 (2019/2021) of the Quality Payment Program (QPP). The Centers for Medicare & Medicaid Services (CMS) continues to implement the Merit-based Incentive Payment System (MIPS) and Advanced Alternate Payment Models (APMs), as required by law (i.e., MACRA), while working to reduce the burden it places on clinicians.

MIPS Year 3 Policy Changes

In working toward the goal of reducing burden, CMS is finalizing its “opt-in” policy, as shown in Table A. Notice that the low-volume threshold includes a “professional services” factor for performance year 2019/payment year 2021. Beginning for the 2018 performance year/2020 MIPS payment year, the low-volume threshold calculations will be based on covered professional services, rather than all Part B items and services.

Table A: MIPS Opt-in Scenarios

Dollars Patients Professional Services Eligible for Opt-in
≤90K ≤200 ≤200 No – excluded
≤90K ≤200 >200 Yes – may voluntarily report
>90K ≤200 ≤200 Yes – may voluntarily report
≤90K >200 >200 Yes – may voluntarily report
>90K >200 >200 No – required to participate

MIPS Comparison Between Year 2 and Year 3

Below is a quick view of the finalized changes to MIPS policy for the 2019 performance year.

Note: Bold items indicate changes from proposed rule.

Year 2 (2018) Final Year 3 (2019) Proposed

MIPS Eligible Clinician Types

MIPS eligible clinicians:

·       Physicians

·       Physician assistants

·       Nurse practitioners

·       Clinical nurse specialists

·       Certified registered nurse anesthetists

MIPS eligible clinicians:

·       Same five clinician types as in Year 1 and 2, PLUS:

o   Clinical psychologists

o   Physical therapists

o   Occupational therapists

o   Qualified speech-language pathologists

o   Qualified audiologists

o   Registered dietitians or nutritionists

MIPS Determination Period

Low-volume Threshold Determination Period:

·       First 12-month segment: Sept. 1, 2016 – Aug. 31, 2017 (including 30-day claims run out)

·       Second 12-month segment: Sept. 1, 2017 to Aug. 31, 2018 (including 30-day claims run out)

Changes to the MIPS Determination Period:

·       First 12-month segment:
Oct. 1, 2017 – Sept. 30, 2018
(including 30-day claims run out)

·       Second 12-month segment:
Oct. 1, 2018 – Sept. 30, 2019
(does not include 30-day claims run out)

Performance Threshold and Payment Adjustments

·       ≥ 70 points: Up to 5% payment adjustment and exceptional performance bonus of 0.5%

·       15.01-69.99: Positive adjustment greater than 0%

·       15 points: Neutral

·       3.76-14.99: Negative payment adjustment greater than -5% and less than 0%

·       0-3.75: Negative payment adjustment of -5%

·       ≥ 75 points: Up to 7% payment adjustment and exceptional performance bonus of 0.5%

·       30.01-74.99: Positive adjustment greater than 0%

·       30 points: Neutral

·       7.51-29.99: Negative payment adjustment greater than -7% and less than 0%

·       0-7.5: Negative payment adjustment of -7%

Virtual Group Elections

·       Must be made by December 31 of calendar year preceding applicable performance period and cannot be changed during performance period.

·       Election process broken into two stages

·       Technical assistance available

Same as in Year 2, except:

·       TINs may inquire about their TIN size prior to making an election during a five-month time frame, August 1 through December 31, prior to the applicable performance period.

·       TIN size inquiries may be made through the QPP service center beginning in payment year 2022.

Quality Performance Category

·       Weight – 50%

·       Bonus Points: 2 points for outcome or patient experience; 1 point for other high-priority measures; 1 point for each measure submitted using electronic end-to-end reporting; cap on bonus points at 10 percent of category denominator

·       Data completeness – 60 percent for submission mechanisms except for Web Interface and CAHPS; measures that do not meet data completeness criteria earn 1 pt (small practices, 3 points)

 

·       Weight – 45%

·       Bonus Points: Same as Year 2, with the addition of a small practice bonus of 6 points for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure

·       Data completeness: Same as Year 2

·       Special considerations:

o   Reduce by 10 points the total measure achievement points for MIPS eligible clinicians who submit a measure significantly impacted by clinician guideline changes or other changes that CMS believes may pose patient safety concerns.

o   Reduce the total available measure achievement points by 10 points if the sample size a group reports to the CAHPS for MIPS survey is insufficient.

·       Topped-out measures – Same as Year 2, except:

o   CMS will remove measures that reach the 98th to 100th percentile range in the next rulemaking cycle, rather than the usual four-year period; and

o   QCDR measures do not qualify for the topped-out measure cycle and special scoring.

·       Removing 26 measures and adding 8.

Cost Performance Category

·       Weight – 10%

·       Measures:

o   Total Per Capita Cost

o   Medicare Spending Per Beneficiary (MSPB)

·       Measure Case Minimums:

o   Case minimum of 20 for Total per Capita Cost measure and 35 for MSPB

·       Weight – 15%

·       Measures:

o   Total Per Capita Cost

o   Medicare Spending Per Beneficiary (MSPB)

o   8 episode-based measures

·       Measure Case Minimums:

o   Case minimum of 10 for procedural episodes

o   Case minimum of 20 for acute inpatient medical condition episodes

·       No improvement scoring

Promoting Interoperability

·       Weight – 25%

·       May use any combination of 2014 and 2015 Edition Certified Electronic Health Record Technology (CEHRT)

·       Performance-based scoring:

o   Comprised of a base, performance, and bonus score

o   Must fulfill base score requirements to earn a score

·       Weight – Same as Year 2

o   Automatic 0 weight for new types of MIPS eligible clinicians/groups

·       Must use 2015 Edition Certified Electronic Health Record Technology (CEHRT)

·       New performance-based scoring:

o   CMS would eliminate the base, performance, and bonus score and score performance at the individual measure level

o   Clinicians would have to report the required measures under each objective or claim the exclusions

·       New measures:

o   ePrescribing:

§  Verify Opioid Treatment Agreement, worth 5 bonus points

§  Query of Prescription Drug Monitoring Program, worth 5 points

o   Health Information Exchange:

§  Support Electronic Referral Loops by Receiving and Incorporating Health Information, worth 20 points

Improvement Activities
·       Weight – 15%

·       Activity weights:

o   Medium = 10 pts

o   High = 20 pts

o   Small practices, non-patient facing clinicians, and clinicians located in rural or HPSAs receive double weight and report on no more than 2 activities to receive highest score

·       Weight – Same as in Year 2

·       Activity weights – Same as in Year 2

·       Improvement Activities:

o   Added 6

o   Modified 5

o   Removed 1

·       Removed the CEHRT bonus to align with the new Promoting Interoperability scoring requirements

 

Misc. Changes:

  • MIPS CQMs replace registry measures
  • Medicare Part B Claims submission mechanism limited to small practices. Individuals can use multiple collection types (MIPS, CQM, eCQM, QCDR measures) to submit quality measures.
  • CMS implementing a facility-based scoring option for clinicians who meet certain criteria, beginning with the 2019 performance period. CMS finalized the policy for facility-based scoring in the 2018 QPP final rule.

Advanced Alternate Payment Models (APMs)

For Advanced APMs in 2019:

What is Macra

  • CMS is increasing the CEHRT use criterion so that an Advanced APM must require at least 75 percent of eligible clinicians in each APM entity to use CEHRT;
  • Allowing eligible clinicians to become Qualifying APM Participants (QPs) starting in 2019 based on a combination of participation in All-Payer Combination option; and
  • Maintaining the revenue-based nominal amount standard at 8 percent through 2024.

A current list of Advanced APMs for 2019 is available on the CMS Quality Payment Program website.

Renee Dustman
Follow me

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman
Follow me

Latest posts by Renee Dustman (see all)

About Has 639 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

Leave a Reply

Your email address will not be published. Required fields are marked *