APMA News - May/June 2018 - 60
Reimbursement
MIPS 2018 Cost Performance Category Requirements
The Quality Payment Program has two participation pathways, the Merit-based Incentive Payment System (MIPS) and
the Alternative Payment Model (APM) incentive payment pathway. Most APMA members will participate in MIPS.
The Cost performance category is one of four categories
included under MIPS, in addition to the Quality, Improvement Activities, and Promoting Interoperability1 performance
categories. The Cost category was included in MIPS to assess
clinicians on their efficient use of resources in the delivery of
care. While performance in this category did not contribute
to a clinician's score under MIPS for 2017-and therefore will
not affect payments for 2019 (based on 2017 performance)-
for 2018, CMS determined that the Cost performance category will contribute to 10 percent of the MIPS Final Score.2 The
MIPS Final Score for 2018 determines whether or not clinicians will receive upward or downward payment adjustments
for Physician Fee Schedule payments in 2020, and what the size
of the adjustments will be.
MIPS Performance Categories and Weights
Performance
Category
2017 Weight
2018 Weight
Quality
60%
50%
Improvement
Activities
15%
15%
Promoting
Interoperability
25%
25%
Cost
0%
10%
provider identifier number combination) or as part of a group
practice (based on a TIN). Additionally, starting with the 2018
performance year, solo practitioners and TINs with 10 or fewer eligible clinicians may have applied for and received approval to participate in MIPS collectively as a virtual group prior to the start of the performance year.
The decision to participate as an individual, group, or
virtual group applies across all four performance categories
for the performance year; for example, physicians who report at the individual level for the Quality, Improvement Activities, and Promoting Interoperability performance categories will be assessed at the individual level for the Cost category.
Additionally, clinicians are required to comply with MIPS for
each unique practice (TIN) with which they are associated, such that clinicians practicing under multiple TINs must
ensure they are meeting MIPS reporting requirements for
each TIN.
For the Cost performance category, MIPS-eligible clinicians
and groups are not required to proactively submit any data to
CMS. Instead, CMS will calculate performance for this category
based on administrative claims data. CMS will review claims
data across the full calendar year to determine performance in
this category for 2018.
Cost Performance Category Measures
For 2018, the Cost performance category largely relies on
measures used in the Physician Value-Based Payment Modifier
(VM) program and reported in previous Quality and Resource
Use Reports (QRURs) delivered under the Physician Feedback
program. These include:
Total Per Capita Cost (TPCC). The TPCC considers all
FFS Medicare Parts A and B costs for all of a physician's
or group's attributed beneficiaries during the performance year.3,4 A beneficiary may be attributed to a specialist only when the beneficiary received no "primary
care services"5 from a primary care provider6 during the
*
Reporting Requirements
MIPS-eligible clinicians may participate in MIPS as individuals (based on a tax identification number [TIN]/national
1 CMS announced on April 24, 2018, that, effective immediately, the Advancing Care Information performance category under MIPS would
be renamed the Promoting Interoperability performance category. Published materials prior to that date referred to the category as the Advancing Care Information performance category.
2 Statute requires that the Cost performance category weight rise to 30 percent by no later than the sixth year of the MIPS program.
3 TPCC is payment-standardized, annualized, risk-adjusted, and adjusted for specialty case-mix.
4 Beneficiaries are attributed to individual clinicians at the TIN/NPI level. For group reporting, beneficiaries attributed to a TIN/NPI in a group
are therefore attributed to the TIN.
5 CMS defines primary care services using the following HCPCS codes: 99201-99205, 99211-99215, 99304-99310, 99315-99316, 99318,
99324-99328, 99334-99337, 99339-99345, 99347-93950, 99487, 99489, 99490, 99495-99496, G0402 (welcome to Medicare visit),
G0438 and G0439 (annual wellness visits), and G0463. Codes 99304-99318 will not be considered primary care services when performed
in a skilled nursing facility (POS 31).
6 CMS limits primary care clinicians to certain physician specialty codes (01-General Practice; 08-Family Practice; 11-Internal Medicine; and
38-Geriatric Medicine) and non-physician practitioner codes (89-Clinical Nurse Specialist; 50-Nurse Practitioner; 97-Physician Assistant).
60 APMA News May/June 2018
Table of Contents for the Digital Edition of APMA News - May/June 2018
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APMA News - May/June 2018 - Cover1
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APMA News - May/June 2018 - Contents
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