Part B Insider (Multispecialty) Coding Alert

Mythbusters:

Debunk 5 QPP Myths With These Facts

Published on Mon May 17, 2021

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See which providers can receive MIPS special status.

COVID-19 may have wreaked havoc on your Quality Payment Program (QPP) numbers, but that doesn’t mean sending your performance data is futile. It’s critical to know the facts to ensure your submissions — and incentive pay — are in line.

Take a look at five common myths about the QPP — and a breakdown of the latest updates and insight addressing Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) misunderstandings.

Myth 1: Regular MIPS is going away in 2022.

Fact: According to the QPP 2021 final rule, the Centers for Medicare & Medicaid Services (CMS) postponed implementing the MIPS Value Pathways (MVP) program until performance year (PY) 2022. And though CMS touts MVPs as the future of MIPS in its guidance, the original basic quality program is still intact.

However, for PY 2021, CMS did add the APM Performance Pathway (APP) for MIPS APMs. But even the APP quality requirements for PY 2021 are skewered by the pandemic’s impact. Currently, APP participants’ quality requirements must be 50 percent of their final score — but special status changes, exception applications, and reweighting can alter that, QPP online guidance indicates.

“Traditional MIPS and the APP are the reporting frameworks available for the 2021 performance period,” and CMS intends “to add the first MVPs for the 2022 performance period” to these existing programs, the final rule fact sheet suggests.

Myth 2: There will be no bonus pay for PY 2020.

Fact: COVID-19 did throw many for a loop, and CMS knows that. The agency has offered some accommodations for individual clinicians, groups, virtual groups, and APMs “mitigat[ing] the increase in patient complexity” due to the pandemic, QPP guidance says.

“In recognition of this additional difficulty and the effect it may have on a provider’s MIPS score, we are doubling the maximum points available for the complex patient bonus from 5 to 10 points (for the 2020 performance year only) to be added to your MIPS 2020 final score,” CMS says. This policy change was solidified in the 2021 QPP final rule.

Myth 3: Only small practices get ‘special status’ under MIPS.

Fact: In actuality, special status is garnered from MIPS-eligible clinicians’ Part B data submitted during determination periods and snapshots — meaning that a whole slew of providers can receive special status depending on whether they meet the criteria.

These Part B submissions from MIPS-eligible clinicians, groups, virtual groups, and APM entities are analyzed and measured against QPP standards. If criteria are determined to match special status standards, the assignment is usually made — but doesn’t show up in the QPP portal until much later in a performance year, online guidance indicates.

The following classifications of MIPS providers are eligible for special status assignment:

Ambulatory Surgery Center-based
Hospital-based
Non-patient facing
Small practice
Rural
Health professional shortage area

Myth 4: An EUC application can erase MIPS providers’ 2020 submissions.

Fact: The Biden administration reopened the COVID-19- inspired 2020 extreme and uncontrollable circumstances (EUC) exception application for clinicians, groups, virtual groups, and APM entities. That extension had a deadline of March 31 and ran adjacent with the MIPS 2020 submission period; plus, CMS allowed MIPS-eligible clinicians impacted by the public health emergency (PHE) to request a reweighting of a performance category.

But: EUC exception applications can’t “override PY 2020 data that has [already] been submitted,” QPP guidance says. “Any data submitted for an individual, group or virtual group (before or after an application has been approved) will be scored. Data submission for an APM Entity won’t override performance category reweighting from an approved application.”

Myth 5: If an individual clinician leaves a group in PY 2020, the MIPS payment adjustment goes to the group for payment year 2022.

Fact: Due to the pandemic, many clinicians have moved around to accommodate clinical demands, family situations, and job changes.

Here’s the way MIPS submissions work in a group practice: Individual MIPS-eligible clinicians submit data under their National Provider Identifiers (NPIs), while the group submits with the Tax Identification Number (TIN). So, if an individual leaves a group in PY 2020, “any payment adjustment associated with that clinician (NPI) will follow the clinician,” the QPP 2020 submission fact sheet explains.

“The payment adjustment will not impact your practice’s payments in 2022 unless the clinician returns to your practice during the 2022 payment year,” the guidance adds.