Cost Performance Category
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.
For the 2022 performance period, Cost will be calculated at 30% of the MIPS final score, as required by MACRA.
Although CMS assesses performance in this category using claims data (instead of data submission or attestation), medical coders, auditors, and practice managers who understand the measures CMS uses to evaluate their clinicians’ claims data can ensure their clinicians meet requirements and score high in this category.
Factor Cost into the MIPS Final Score
With cost now 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 2022 is a Medicare Part B payment adjustment somewhere between plus or minus 9% in payment year 2024.
Review Cost Measures for Clues
In performance year 2022, CMS will evaluate a clinician’s cost using 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 25 cost measures and 23 MIPS episode-based cost measures for the 2022 performance period:
- Total Per Capita Cost for All Attributed Beneficiaries (TPCC)
- Medicare Spending Per Beneficiary (MSPB)
- 15 procedural episode-based measures
- 6 acute inpatient medical condition episode-based measures
- 2 chronic condition episode-based measures
In 2022, there are five new episode-based cost measures, one of which as a new measure attribution framework for identifying and confirming a clinician-patient relationship.
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 Medicare patients.
Table A: Applicable primary care services for the TPCC measure
|CPT®/HCPCS Level II Code
||New patient, office, or other outpatient visit
||Established patient, office, or other outpatient visit
||New patient, nursing facility care
||Established patient, nursing facility care
||Established patient, discharge day management services
||New or established patient, other nursing facility service
||New patient, domiciliary or rest home visit
||Established patient, domiciliary or rest home visit
||Established patient, physician supervision of patient (patient not present) in home, domiciliary, or rest home
||New patient, home visit
||Established patient, home visit
||Complex chronic care management
||Transitional care management
||Chronic care management
||Initial Medicare visit
||Annual wellness visit, initial
||Annual wellness visit, subsequent
||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 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% 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 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
||Trigger Code(s) or MS-DRG(s)
|Routine Cataract Removal with Intraocular Lens (IOL) Implantation
|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
|Revascularization for Lower Extremity Chronic Critical Limb Ischemia
||35302-35305, 35371, 35372, 35556, 35570, 35571, 35583, 35585, 35587, 35656, 35671, 37224-37231
||45378, 45380, 45381, 45384, 45385, G0105, G0121
|ST-Elevation Myocardial Infarction (STEMI)
Create a Line of Defense
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:
- 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.
- Determine if clinicians may be assessed under any of the eight episode-based measures by auditing claims for:
- Episode triggers and windows
- Item and service assignment
- Attribution methodology
- Risk adjustment variables
- Review benchmarks to determine achievement points and calculate a Cost performance category score (for comparison purposes).
What Are CMS Cost 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 MIPS-eligible clinician’s 2021 Cost performance category won’t be made public until the summer of 2022.
To calculate the Cost performance category for 2022 performance, 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.
The Cost performance category score formula is:
[Earned Points] ÷ [Total Possible Points] = [Percentage]
[Percentage] x [Weight] = [Score]
MIPS Final Score
Performance in the four MIPS categories, plus bonus points, factor into a clinician’s annual MIPS score, which CMS caps at 100 points. The category breakdown for the 2022 performance year is:
- Quality 30% weight
- Cost 30% weight
- Promoting Interoperability 25% weight
- Improvement Activities 15% weight
- Small Practice Bonus 5 MIPS points
- Complex Patient Bonus 10 MIPS points maximum
For the 2022 performance year, CMS modified the performance category weight redistribution policy for small practices:
- When Promoting Interoperability is reweighted to 0%, the Quality performance category will be weighted at 40% and both the Cost and Improvement Activities performance categories will be weighted at 30%.
- When both the Promoting Interoperability and Cost performance categories are reweighted, both the Quality and the Improvement Activities performance categories will be weighted at 50%.
The APM Performance Pathway (APP) is a streamlined reporting framework available beginning with the 2021 performance year for MIPS eligible clinicians who participate in a MIPS APM.
MIPS Value Pathways (MVPs) are subsets of measures and activities that can be used to meet MIPS reporting requirements beginning with the 2023 performance year. There are seven MVPs that will be available for reporting in the 2023 performance year:
- Advancing Rheumatology Patient Care
- Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes
- Advancing Care for Heart Disease
- Optimizing Chronic Disease Management
- Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
- Improving Care for Lower Extremity Joint Repair
- Support of Positive Experiences with Anesthesia
Clinicians will be able to report individual measures in Traditional MIPS until CMS fully implements MVPs.
Last Reviewed on Apr 11, 2022 by AAPC Thought Leadership Team