MIPS (Merit-Based Incentive Payment System)

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is federal legislation that required the Centers for Medicare & Medicaid Services (CMS) to create the Merit-Based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP). The QPP is designed to reward eligible clinicians for the value of care they provide rather than the volume of care they provide. Payment adjustments are based on performance points scored according to national benchmarks. Each performance year, an eligible clinician’s MIPS final score determines their future Medicare Part B payment adjustments and creates a means for CMS to rate providers against national peers.

As mandated by the Bipartisan Budget Act, CMS has gradually increased the MIPS performance threshold toward the goal of establishing the national historical median by the 2022 performance year/2024 payment year.

MIPS eligible clinicians participating in the program are scored on resource use, quality, clinical practice improvement, and electronic health record (EHR) utilization. As mounting MIPS performance requirements raise measurement-based financial and reputational stakes, clinicians must maintain or exceed the pace of their peers.

How important is your 2022 MIPS performance? Consider a few bottom-line facts as you head into MACRA Year 6.

FACT 1—MIPS Is Competition

MIPS measures are assigned points, which are scored according to national benchmarks. This means you’re in competition with every practitioner in the country. MIPS demands an organization-wide commitment to continuous performance improvement for positive payment adjustments.

FACT 2—MIPS Is Marketing

Beginning in 2018, MACRA required CMS to publish MIPS composite scores and other MIPS data through its Physician Compare initiative.

MIPS publishes each practitioner’s final score within 12 months following the performance year, allowing consumers to see their practitioners rated on a 100-point scale and learn how they compare to other healthcare providers.

Transparent MIPS scores impact revenue connected to patient attraction and retention, but the ramifications come with greater liability. CMS ties the MIPS score to the practitioner, so that if the practitioner changes practices, they bring along the score, which then influences physician recruiting, contracting, and compensation plans.

The effects of one low-performing year, in other words, extend several years beyond the corresponding payment year.

If you had a low-performing year, your quickest route to recovery is to invest every effort in following up with a record-high performance.

FACT 3—MIPS Incentives Are Funded by Penalties

MIPS must remain budget neutral. This means that high performers can tip the scales in their favor, leaving low performers to fund their positive payment adjustments.

Amid escalating competition for incentives, MIPS eligible clinicians who ensure their medical coders, billers, and practice managers receive effective annual MACRA education will have the advantage and bank substantial gains on their investment.

MIPS Performance Categories

MIPS tracks data in four performance categories:

• Quality,

• Cost,

• Improvement Activities, and

• Promoting Interoperability.

Quality Performance Category

The Quality component of MIPS is the highest weighted performance category, worth at least 30% of a clinician or group’s MIPS final score in the 2022 performance year.CMS set the data completeness threshold at 70% (for Part B claims, QCDR measures, MIPS CQMs, and eCQMs) of all eligible encounters.

Note: Administrative claims measures, CMS Web Interface measures, and the Consumer Assessment of Healthcare Providers Survey (CAHPS) for MIPS measures have different data completeness requirements. If a measure’s criteria are not met, the clinician could earn as little as 1 point (3 points for small practices) for a measure.

As of 2019, CMS reduced the Quality denominator by 10, and the measure will receive 0 points for groups that submit five or fewer quality measures and do not meet the CAHPS for MIPS sampling requirements.Follow these steps to determine the number of encounters you need to submit to meet a measure’s data completeness criteria:

1. Choose measures applicable to the practice.

2. Determine the eligible populations, per measure specifications, such as demographics and codes.

3. Verify reporting frequency, per measure specifications, and multiply it by the determined population (this is your eligible instances).

4. Divide your eligible instances by 60% to learn your minimum number of submissions to meet data completeness.

Quality Performance Category Reporting Requirements

To achieve the highest score in this category (60 points), clinicians will need to report on at least six quality measures, including at least one outcome measure or high-priority measure. Clinicians can choose from over 200 measures and must collect a full calendar year of data.

Specialty Set Measures

While providers aren’t restricted to measures listed in the specialty sets that apply to them, they may find these sets helpful when selecting measures. Ultimately, providers should choose measures based on how their performance compares with corresponding benchmarks and their ability to meet case minimums.Always refer to measure specifications to verify applicable measures — even for those measures within the provider’s specialty set, as not all will be applicable. If the specialty set includes less than six applicable measures, report only the applicable measures. For the selected measures, make sure the case minimum can be met.

All-Cause Hospital Readmission

Practices with 16 or more providers and at least 200 eligible cases are included in the additional measure for All-Cause Hospital Readmissions. CMS will calculate this measure from claims data and will score in the same way as the other Quality measures (that have benchmarks), from 3 to 10 points.With the All-Cause Hospital Readmissions measure, the maximum increases from 60 Quality measure points to 70 Quality measure points (110 to 120 points if reporting via the CMS Web Interface). Clinician groups that submit their data via the CMS Web Interface and administer the CAHPS for MIPS survey have 130 points available.

Improvement Activities Performance Category

The Improvement Activities (IA) performance category focuses on care coordination, beneficiary engagement, and patient safety.The IA category is worth 15% of the MIPS final score. To get full credit in this category, a clinician or group must:

• Complete activities equal to a maximum 40 points; or

• Participate a in a patient-centered medical home or similar specialty society and attest to participation; or

• Participate in an APM and submit data for one or more MIPS performance categories and attest to additional activities to achieve at least 20 points.

For the 2022 performance year, CMS added seven new improvement activities, including the Create and Implement an Anti-Racism Plan, and remove six improvement activities.Clinicians can calculate their performance in this category with AAPC’s MIPS calculator—or use the following scoring formula for Improvement Activities (IA):

IA Score = Total points for completed activities / 40 x 15

Clinicians earn points with high-weighted activities worth 20 points each and medium-weighted activities worth 10 points each. Certain clinicians earn double-points for each improvement activity (High-weighted activities are worth 40 points, and medium-weighted activities are worth 20 points.):

• Small practices

• Providers in practices located in a rural area (in a ZIP code designated as rural in the most recent HRSA Area Health Resource File data set)

• Providers in practices located in a geographic Health Professional Shortage Area

• Non-Patient Facing Providers or Groups

Patient-facing encounter codes determine non-patient facing status. A non-patient facing MIPS eligible clinician is:

• An individual who bills 100 or fewer patient-facing encounters (including telehealth)

• A group with 75% of the clinicians billing under the group’s TIN meeting the definition of a non-patient facing individual

The list of patient-facing encounter codes includes evaluation and management (E/M) codes and surgical and procedural codes.To earn full credit for an activity, clinicians must perform the activity for 90 continuous days during the performance period.A group or virtual group may attest to an improvement activity when at least 50% of its MIPS eligible clinicians participate in or perform the activity. At least 50% of the group’s NPIs must perform the same activity for the same continuous 90 days in the performance period.Because this performance category will be reported through attestation, clinicians should maintain documentation to justify their Yes/No statement in case of an audit.

Promoting Interoperability Performance Category

Promoting Interoperability replaced Meaningful Use to continue the effort for secure exchange of health information and the use of certified EHR technology (CEHRT). For most providers, this category is worth 25% of the MIPS final score.In some cases, a provider may qualify for an exception from this performance category. In these circumstances, the Promoting Interoperability performance category is reassigned a weight of 0% and the Quality performance category is increased by 25%.Beginning in Year 3, the MIPS provider must use 2015 CEHRT. The 2022 Promoting Interoperability performance category focuses on the following objectives:

• Health Information Exchange (HIE)

• Provider to Patient Exchange

• Public Health and Clinical Data Exchange

• ePrescribing

Clinicians are required to report five to six measures from each of the four objectives in addition to required attestations, unless an exclusion is claimed. The required attestations are:

• Prevention of Information Blocking

• SAFER Guides

• ONC Direct Review

• Security Risk Analysis

MIPS eligible clinicians who may qualify for an automatic exception from this category include:

• Hospital-based clinicians (those with 75% or more of their Medicare encounters occurring in place of service 21 (hospital), 22 (on-campus outpatient hospital), or 23 emergency room)

• Non-patient facing clinicians (those who don’t typically see patients face-to-face (e.g., radiology, anesthesiology) who bill fewer than 100 patient-facing CPT^® codes to Medicare in a 12-month period). CMS has provided a list of the 

  patient-facing CPT^® codes

  . If reporting as a group, at least 75% of the eligible clinicians in the group must meet the non-patient facing criteria.

• Ambulatory surgical center-based clinicians

• Small practices

MIP Scoring – Promoting Interoperability

The scores for each of the individual measures will be added together to calculate the score of up to 100 possible points. If exclusions are claimed, the points for measures will be reallocated to other measures.

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

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

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

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:

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:

   • Episode triggers and windows

   • Item and service assignment

   • Exclusions

   • Attribution methodology

   • Risk adjustment variables

3. 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:

1. Advancing Rheumatology Patient Care

2. Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes

3. Advancing Care for Heart Disease

4. Optimizing Chronic Disease Management

5. Adopting Best Practices and Promoting Patient Safety within Emergency Medicine

6. Improving Care for Lower Extremity Joint Repair

7. Support of Positive Experiences with Anesthesia

Clinicians will be able to report individual measures in Traditional MIPS until CMS fully implements MVPs.