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MIPS survival guide for 2018: How to avoid a negative adjustment

By Grant Huang
Director of Content at DoctorsManagement

January marks the start of the second year of Medicare’s Merit-based Incentive Payment System (MIPS) – but the end of the transition year. That means tougher minimum reporting requirements just to avoid a negative payment adjust in 2020, although next year will also make MIPS easier in other ways thanks to the Quality Payment Program (QPP) final rule for 2018.

In this article we’ll discuss the changes to MIPS from 2017 to 2018 as well as the steps needed to meet the minimum reporting requirements. In the next issue of The Business of Medicine, we will explore ways to maximize your MIPS composite score should your practice desire to earn MIPS bonus payments and a share of cash from the exceptional performance pool.

Check your eligibility, again: Some of your providers could be off the hook in 2018 because CMS has significantly expanded the “low-volume” threshold below which providers were exempt from having to participate in MIPS. For an individual provider, this threshold was set at $30,000 or less in total annual Part B charges or seeing 100 or fewer Medicare beneficiaries per year. This threshold is increasing substantially for 2018: A provider who bills $90,000 or less in Part B charges a year, or who sees 200 or fewer beneficiaries per year, will be exempt from MIPS. You can visit this CMS website and enter each provider’s national provider identifier (NPI) to see if he or she is required to participate in MIPS for 2018.

2018 MIPS: Getting by with the bare minimum

To avoid a 5% negative payment adjustment in 2020, providers who are eligible for MIPS must earn a MIPS composite score of at least 15 points. Remember: MIPS is composed of four categories, each of which – while weighted differently – contributes points to a single composite score. The composite score is used to determine payments and penalties.

Achieving the 15-point minimum score is much tougher in 2018 (the minimum score was only 3 points in 2017). However, it can be achieved in a few ways:

Full participation in the Improvement Activities category such as, submitting one high-weighted activity and two medium-weighted activities for small practices or, two high-weighted activities, four medium-weighted activities, or a combination of both;

Completing the Advancing Care Information (ACI) base score and one quality measure meeting the measure threshold or data completeness requirement, but not benchmarks;

Reporting the required base measures for the ACI category and one medium-weighted improvement activity; or

Reporting six quality measures to meet data completeness, but not measure benchmarks.

Big bonuses for complex patients  and small practices

One final piece of the MIPS puzzle to remember is that under the 2018 QPP final rule, CMS is handing out free bonus points for treating complex patients and for small practices. Here’s how they work.

Complex patients bonus will be based on your ICD-10 coding. You get up to 5 points toward your composite score. CMS will calculate this bonus automatically by crosswalking your patients’ ICD-10 diagnoses to Hierarchical Condition Categories (HCC) to produce an average HCC risk score, which is then added to the dual eligible (patients eligible for Medicare and Medicaid) ratio and multiplying the result by 5. To maximize your chances of getting points for complex patients, make sure your providers select ICD-10 codes to the maximum level of specificity, and report any applicable secondary diagnoses to capture the full complexity of every patient visit.

Small practice bonus will be based on your ICD-10 coding. Like the complex patients bonus, the small practice bonus is worth up to 5 points toward the composite score, and it’s calculated automatically by CMS. Any practice with 15 or fewer MIPS-eligible providers will get 5 points (either individually or as a group depending on how they report). What’s more, small practice will receive no fewer than 3 points for any quality measure submitted. Even more significantly, small practices may claim a significant hardship for the ACI category. If the claim is approved by CMS, the ACI category weight will be redirected to the Quality category, making Quality account for a total of 85% of the MIPS composite score. The ACI hardship is available if a practice or provider has insufficient Internet connectivity, extreme and uncontrollable circumstances, or lack of control over the availability of certified EHR technology. Finally, small practices will get full credit in the Improvement Activities category by submitting one high-weighted activity.

The best thing about these two sources of bonus points is that they can count toward your 15-point minimum. If you are a small practice, you have 5 points to start with and your path to minimum reporting is already one-third complete. Look for a guide to maximizing your composite score and earning as much bonus payments as possible under MIPS in the upcoming January 2018 issue of The Business of Medicine.

Author: Grant Huang (