Ignore New MIPS Requirements at Your Own Risk

Ignore New MIPS Requirements at Your Own Risk

A 7 percent payment update in your professional claims is at stake.

That’s a nice bonus on top of the automatic 0.5 percent update to the Physician Fee Schedule (PFS). This is the last year for the automatic update, however. The only shot clinicians have at a PFS payment update in 2020 and beyond is to participate in either MIPS or an Advanced Alternative Payment Model (APM) under the QPP.
Here we are, Payment Year 1 and Performance Year 3 of the Quality Payment Program (QPP), already. According to the Centers for Medicare & Medicaid Services (CMS), 93 percent of clinicians who were eligible to participate in the Merit-based Incentive Payment System (MIPS) — one of two tracks under the QPP — will receive a positive payment adjustment of 0.28 to 1.88 percent this year for their MIPS performance in 2017.
Clinicians who were eligible to participate in Performance Year 2, who did not participate in an Advanced APM, are due to submit their MIPS 2018 data between now and March 31 (depending on submission mechanism). Their final score will determine whether they see a positive or negative payment update of up to 5 percent in 2020. Let’s look at what is required of MIPS eligible clinicians this year.

Determine Eligibility

To secure a positive payment update to professional service claims in 2021, eligible clinicians must participate in MIPS or an Advanced APM. CMS has expanded the MIPS playing field this year in a couple of ways.
For 2019, MIPS eligible clinician types are:

  • Physicians (including doctors of medicine, doctors of osteopathy, chiropractors, dentists, optometrists, and podiatrists)
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialist
  • Certified registered nurse anesthetists
  • Physical therapists (New)
  • Occupational therapists (New)
  • Qualified speech-language pathologists (New)
  • Clinical psychologists (New)
  • Registered dietitians or nutrition professionals (New)

MIPS eligible clinicians who meet or exceed the low-volume threshold are required to participate in the QPP. Clinicians’ status may be different than last year because the methodology used to determine MIPS participation status now includes a Professional Services criterion. Also, MIPS eligible clinicians can now opt in (or voluntarily report) if they meet or exceed at least one criterion, as shown in Table A.
Table A: Low-volume Threshold

Dollars (PFS) Medicare patients Professional Services (PFS) Eligible for Opt-in?*
≤ 90K ≤ 200 ≤ 200 No, excluded from MIPS
≤ 90K ≤ 200 > 200 Yes (or report voluntarily)
> 90K ≤ 200 ≤ 200 Yes (or report voluntarily)
> 90K ≤ 200 > 200 Yes (or report voluntarily)
≤ 90K > 200 > 200 Yes (or report voluntarily)
> 90K > 200 > 200 No, required to participate

* Those who opt in qualify for +/- payment adjustments and those who voluntarily report do not.
Tip: Clinicians can verify their participation status.

Meet MIPS Performance Category Requirements

In MIPS, there are four performance categories in which clinicians are scored. Each category is weighted toward a final possible score of 100 points. The performance categories and weights for 2019 are:

  •     Quality – 45 percent
  •     Cost – 15 percent
  •     Promoting Interoperability – 25 percent
  •     Improvement Activities – 15 percent

Note that Quality measures weigh in a bit less this year, and Cost measures weigh in a bit more. This balancing act will continue until both Cost and Quality account for 30 percent of the final composite score.
There are also changes to the requirements clinicians must meet for each performance category. Briefly stated:
Quality – The 6-point bonus for small practices will apply to the Quality performance category, rather than the final score. Small practices (with 15 or fewer clinicians) need only submit data on at least one quality measure to earn this bonus.
Cost – In addition to the Total Per Capita Cost and Medicare Spending Per Beneficiary measures, CMS is adding eight episode-based measures to this performance category, with a case minimum of 10 for procedural episodes and 20 for acute inpatient medical condition episodes. CMS will attribute episodes to each MIPS eligible clinician who renders a trigger service (identified by HCPCS Level II/CPT® codes). For acute patient medical condition episodes, CMS will attribute episodes to each MIPS eligible clinician who bills inpatient evaluation and management (E/M) claim lines during a trigger inpatient hospitalization under an entity that renders at least 30 percent of the inpatient E/M claim lines in that hospitalization.
Promoting Interoperability – There are significant changes to this performance category for 2019 such as the requirement to use only 2015 Edition certified electronic health record technology (CEHRT). Realizing the financial burden this puts on solo clinicians and small clinician groups, CMS will continue to accept hardship exception applications for this category. Newly eligible types are automatically exempt from this category; and the 25 percent weight is reassigned to the Quality performance category.
Another big surprise is the new scoring methodology for this category. Instead of calculating base, performance, and bonus scores, CMS will score performance at the individual measure level. A security risk analysis is still required but no points will be given. The new point system is shown in Table B.
Table B: Promoting Interoperability Point Value

Objectives Measures Maximum Points
ePrescribing ePrescribing 10 points
Query of Prescription Drug Monitoring Program (New) 5 bonus points
Verify Opioid Treatment Agreement (New) 5 bonus points
Health Information Exchange Support Electronic Referral Loops by Sending Health Information (formerly Send a Summary of Care) 20 points
Support Electronic Referral Loops by Receiving and Incorporating Health Information (New) 20 points
Provider to Patient Exchange Provide Patients Electronic Access to Their Health Information (formerly Provide Patient Access) 40 points
Public Health and Clinical Data Exchange Immunization Registry Reporting
Electronic Case Reporting
Public Health Registry Reporting
Clinical Data Registry Reporting
Syndromic Surveillance Reporting
10 points

Improvement Activities – For the 2019 performance period, MIPS eligible clinicians can score points for conducting a public health emergency activity, and six other new activities. Read the measure specifications carefully, as five are modified and one is deleted. Also, clinicians can no longer earn a Promoting Interoperability bonus under this category.

Score High for the Best Return on Investment

To ensure a neutral payment adjustment in 2021, clinicians must meet a performance threshold of 30 points in 2019 – up from 15 points in 2018 and 3 points in 2017. A positive payment adjustment can be earned by earning a final score (the sum of all performance categories) between 30.01 and 74.99 points. The threshold for the exceptional performance bonus of 0.5 percent is 75 points, compared to 70 points last year. As in Year 2, clinicians can earn up to an additional 5 bonus points for treating complex patients.

Act Now to Ensure Future Success

Although 95 percent of MIPS eligible clinicians overall avoided a negative payment adjustment this year, participation gets harder each year. Clinicians will need to pay closer attention to the requirements to perform well. MIPS eligible clinicians who do nothing are guaranteed a negative 7 percent payment update in 2021. Doing nothing is not an option.
If this is all Greek to you, go online to learn all about MIPS and APMs. AAPC offers MACRA training so you can add MACRA proficiency to your resume.

CPB : Online Medical Billing Course

Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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