Help Clinicians Factor Cost into the MIPS Equation
Medical coders and auditors are essential to their employer’s outcome in the Cost performance category.
Of the four performance categories in the Merit-based Incentive Payment System (MIPS), — one of two tracks for participation in the Quality Payment Program (QPP) — Cost is the most worrisome because clinicians do not have control over this portion of their final score. Or do they?
Although the Centers for Medicare & Medicaid Services (CMS) assesses performance in this category using claims data (instead of data submission or attestation), support staff who understand the measures CMS uses to evaluate their clinicians’ claims data will be worth their weight in gold.
Factor Cost into the MIPS Final Score
The goal of the Cost performance category is to track national healthcare spending and to use the resulting data, adjusted for risk and other factors, to create benchmarks (see the accompanying sidebar, “What Are Benchmarks?”) for value-based care. CMS uses these benchmarks as a gauge for performance.
The Cost performance category is worth 15 percent of an eligible clinician or group’s MIPS final score this year. By 2022, it will be worth 30 percent, as required by the Medicare Access and CHIP Reauthorization Act (MACRA). With cost quickly becoming a significant factor in the MIPS final score — the determining factor for MIPS payment adjustments — time is of the essence for clinicians to assess their performance.
The motivation to do so in performance year 2019 is a Medicare Part B single conversion factor somewhere between plus or minus 7 percent in payment year 2021.
The Cost performance category is assigned a weight of 0 percent for MIPS eligible clinicians who will be scored under the Alternate Payment Model (APM) — a second track for participation in the QPP — scoring standard because these MIPS APM participants are already being assessed on cost and utilization through their APM entity.
Review Cost Measures for Clues
This year, CMS will evaluate cost using eight episode-based measures in addition to the two measures used the previous two years (clinicians weren’t scored the first year of MIPS, but data was collected). The measures for this performance period are:
- Total Per Capita Cost for All Attributed Beneficiaries (TPCC)
- Medicare Spending Per Beneficiary (MSPB)
- Episode-based measures:
- Elective Outpatient Percutaneous Coronary Intervention
- Knee Arthroplasty
- Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Routine Cataract Removal with Intraocular Lens Implantation
- Screening/Surveillance Colonoscopy
- Acute Inpatient Medical Condition
- Intracranial Hemorrhage or Cerebral Infarction
- Simple Pneumonia with Hospitalization
- ST-Elevation Myocardial Infarction with Percutaneous Coronary Intervention
Understand Measured Criteria
Each measure’s criteria are different, so let’s look at them individually to ascertain what is being measured and how.
Total Per Capita Costs
The TPCC measure assesses total Medicare Parts A and B expenditures for a patient attributed to an individual clinician or clinician group during a performance period (Jan. 1 – Dec. 31) by calculating the risk-adjusted, per capita costs. Patients are attributed to a clinician or clinician group based on the amount of primary care services (shown in Table A) they received by their primary care clinician (PCC) — or specialist, if they don’t see a PCC — during the performance period. Attributable patients must reside in the United States and be enrolled in both Medicare Parts A and B (unless newly enrolled) for the full year. The case minimum for this measure is 20 attributable patients.
Table A: Applicable primary care services for the TPCC measure
Level II Code
|99201-99025||New patient, office, or other outpatient visit|
|99211-99215||Established patient, office, or other outpatient visit|
|99304-99306||New patient, nursing facility care|
|99307-99310||Established patient, nursing facility care|
|99315-99316||Established patient, discharge day management services|
|99318||New or established patient, other nursing facility service|
|99324-99328||New patient, domiciliary or rest home visit|
|99334-99337||Established patient, domiciliary or rest home visit|
|99339-99340||Established patient, physician supervision of patient (patient not present) in home, domiciliary, or rest home|
|99341-99345||New patient, home visit|
|99347-99350||Established patient, home visit|
|99487-99489||Complex chronic care management|
|99495-99496||Transitional care management|
|99490||Chronic care management|
|G0402||Initial Medicare visit|
|G0438||Annual wellness visit, initial|
|G0439||Annual wellness visit, subsequent|
|G0463||Hospital outpatient clinic visit (electing teaching amendment hospitals only)|
Medicare Spending Per Beneficiary
The MSPB measure assesses total Medicare Parts A and B expenditures incurred by a single patient attributed to an individual clinician or clinician group during the episode window (up to three days prior to, during, and 30 days following a qualifying inpatient hospital stay) and compares these costs to expected costs.
Each patient MSPB episode is attributed to the MIPS eligible clinician who billed the largest amount of Medicare Part B-allowed charges during the episode window (barring exclusions). The minimum case volume for this measure is 35 patients.
Episode-based measures only look at items and services related to applicable episodes of care, identified by procedure and diagnosis codes reported on Medicare B claims or Medicare Severity Diagnosis-related Group (MS-DRG) codes on Medicare Part A claims.
Each episode-based measure (listed above) has a corresponding measure code list file. The Measure Codes List file is an Excel workbook that provides clinicians with the specific codes and logic that apply to the Cost measure, including episode triggers (applicable codes for the measure), exclusions, episode sub-groups, assigned items and services, and risk adjusters (e.g., Hierarchical Condition Category codes).
Acute Inpatient Medical Condition measures are a little different than Procedural measures in that the episodes are attributed to each MIPS eligible clinician who bills inpatient evaluation and management (E/M) claim lines during a trigger inpatient hospitalization — determined by the MS-DRG — under a Tax Identification Number (TIN) that renders at least 30 percent of the inpatient E/M claim lines in that hospitalization.
Episode-based measures have minimum case volumes that the MIPS eligible clinician or group must meet to be scored on a given measure:
- The minimum case volume for Procedural measures is 10 episodes.
- The minimum case volume for Acute Inpatient Medical Condition measures is 20 episodes.
MIPS eligible clinicians and their support staff should review each measure’s specifications and code list (available for download at qpp.cms.gov) to determine which ones CMS uses to score them. Table B lists each episode-based measure’s trigger codes. Review the actual files for complete metrics.
Table B: Episode-based measures descriptions and trigger codes
|Measure||Trigger Code(s) or MS-DRG(s)|
|Routine Cataract Removal with Intraocular Lens (IOL) Implantation||66984|
|Intracranial Hemorrhage or Cerebral Infarction||MS-DRG 064-066, 070-072|
|Elective Outpatient Percutaneous Coronary Intervention (PCI)||92920, 92921, 92928, 92929, 92933, 92934, 92937, 92938, 92943, 92944, C9600-C9608|
|Simple Pneumonia with Hospitalization||MS-DRG 93-95|
|Revascularization for Lower Extremity Chronic Critical Limb Ischemia||35302-35305, 35371, 35372, 35556, 35570, 35571, 35583, 35585, 35587, 35656, 35671, 37224-37231|
|Screening/Surveillance Colonoscopy||45378, 45380, 45381, 45384, 45385, G0105, G0121|
|ST-Elevation Myocardial Infarction (STEMI)||MS-DRG 246-251|
Create a Line of Defense
Beginning with the 2022 MIPS performance period/2024 MIPS payment year, the Cost performance category percent score takes into account improvement scoring. Plan now for a positive future. And remember: Your best defense is always documentation and coding that justifies the quality care your clinicians provide.
Take Control of Cost
Three critical steps help clinicians assess their performance in this MIPS category:
1. Determine if clinicians meet case minimums of attributable patients for the Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost for All Attributed Beneficiaries (TPCC) measures.
2. Determine if clinicians may be assessed under any of the eight episode-based measures by auditing claims for:
a. Episode triggers and windows
b. Item and service assignment
d. Attribution methodology
e. Risk adjustment variables
3. Review benchmarks to determine achievement points and calculate a Cost performance category score (for comparison purposes).
What Are Benchmarks?
CMS establishes a single, national benchmark for each Cost measure, based on claims data from the performance period. As such, there’s an approximate six-month lag between the performance period ending and clinicians finding out how they measured up. For example, the Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost for All Attributed Beneficiaries (TPCC) benchmarks used to determine a Merit-based Incentive Payment System (MIPS)-eligible clinician’s 2018 Cost performance category won’t be made public until this summer.
To calculate the Cost performance category for 2019 performance, the Centers for Medicare & Medicaid Services (CMS) will assign one to 10 achievement points to each scored measure based on the clinician or clinician group’s performance on the measure compared to the performance period benchmark.
This year, there are 10 Cost measures, for a possible 100 points total; and the weight of this category is 15 percent (.15).
The Cost performance category score formula is:
[Earned Points] ÷ [Total Possible Points] = [Percentage]
[Percentage] x [Weight] = [Score]
2019 Merit-based Incentive Payment System (MIPS) Cost Performance Category Fact Sheet
2019 Cost Measure Information Forms
2019 Cost Measure Code Lists
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