MIPS 2018 Survival Guide: Maximizing your score and bonus MIPS 2018 Survival Guide: Maximizing your score and bonus
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MIPS 2018 survival guide: Maximizing your score and bonus

By Grant Huang, CPC, CPMA

Director of Content at DoctorsManagement

The 2018 performance year for Medicare’s Merit-based Incentive Payment System (MIPS) is well underway and it’s time to look at how you can maximize your providers’ MIPS score for a shot at the exceptional performance bonus payment, which will be added to the positive payment adjustment you receive in 2020 for full MIPS participation.

Remember: We looked at how to achieve the minimum MIPS score (15 points) required to avoid a negative adjustment in 2020 in last month’s issue of The Business of Medicine. In this article, we will describe the benefits of hitting the exceptional performance threshold (70 points) and how to do so.

2018 MIPS score breakdown

The changes made to MIPS as part of the Quality Payment Program (QPP) final rule for 2018 include new ways to score bonus points (for complex patients, small practices). We will discuss those bonuses later in this article. What hasn’t changed is the point goal: You need a MIPS composite score (sometimes simply called the MIPS “final score”) of at least 70 points to qualify for the exceptional performance bonus.

The highest possible MIPS score is 100 points and those providers or groups managing to reach 100 points will be guaranteed not only the maximum positive payment adjustment of 5% in 2020, they will also receive the highest exceptional performance bonus. The exceptional performance bonus comes from a $500 million pool of money set aside from the rest of the MIPS budget, which is designed to be neutral (those providers failing to meet the minimum threshold each year will get negative updates that help pay for the positive updates of the successful MIPS reporters).

Reaching the 70-point minimum for the exceptional performance threshold ensures at least a 0.5% positive payment boost on top of the maximum 5% positive update. The point threshold to receive the maximum 5% positive update will depend on how many providers choose to participate in MIPS for 2018 and on how well they do, but it is expected to be short of the 70-point mark for the exceptional performance bonus.

2018 MIPS performance categories

There are four MIPS categories: Quality, Advancing Care Information (ACI), Improvement Activities, and Cost. In 2018, the Quality performance category goes from accounting for 60% of your MIPS score to 50%, with the 10% difference going toward the Cost performance category (which was not scored in the 2017 performance year).

Tip: Don’t be confused by the CMS usage of percentages for each category above. Because the highest possible MIPS score is 100, the denominator is effectively 100 which means each category’s percentage weight represents the maximum number of points it can contribute to the score. For example, the Quality category is weighted at 50% which means even submitting half of the required Quality measures will yield 25 points and meet the minimum threshold (15 points).

Your best chance to hit or exceed a MIPS final score of 70 points requires performing well on Quality and ACI, the two biggest pieces of the MIPS pie in 2018. A full score for both categories would yield 75 points even with no points from the other categories.

Quality performance category

For this category, providers must report six Quality measures (many adopted from the Physician Quality Reporting System or PQRS), including at least one outcome measure or high priority measure. There are a total of 271 Quality measures available, including new specialty measure sets that are designed to better reflect the specific clinical conditions addressed by various specialists.

Small practices (defined as 15 or fewer providers for the purposes of this category) have an advantage; they don’t have to report an additional hospital readmission Quality measure. For any Quality measure to count, it must be based on at least 20 patient encounters. All you can control is which Quality measures to report; CMS will score your performance on those measures and award you up to 10 points toward the Quality category score. The more measures you report, the more chances you have of maxing out your Quality category score (which accounts for up to 50 points of your MIPS final score).

ACI performance category

For this category, you must report base measures and performance measures. Base measures reflect fundamental EHR functionality such as the ability to issue electronic prescriptions. Performance measures span various categories and are based on the EHR Meaningful Use (MU) program measures from earlier years.

There are five base measures and 10 performance measures; the ACI category score is calculated using both. However, the base measures are mandatory and account for up to 50 points within the ACI category. The performance measures are optional and allow you to reach the maximum ACI category score of 100 points if you report enough of them. Achieving the maximum ACI category score of 100 points will yield 25 points toward your MIPS final score (because ACI is weighted at 25% of the MIPS final score).

Collect all the bonuses you can

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.

  • Bonus points for improving from 2017. CMS will award up to 10 bonus points toward the 2018 MIPS final score for all providers who demonstrate any improvement to either their Quality or Cost performance category score from 2017. Remember, the Cost category wasn’t scored in 2017, but CMS did calculate it.
  • Bonus points for using the latest EHRs. You get up an extra 10% bonus to your ACI category score for reporting at least 90 days of ACI measures using an EHR system that has the 2015 Certified EHR Technology (CEHRT) certification. Many systems still use the older, 2014 CEHRT certification, which CMS is allowing for MIPS reporting, but the bonus will only apply if your system as the 2015 certification.
  • New: Up to 5 points for complex patients. 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.
  • New: 5 bonus points for small practices. Like the complex patients bonus, the small practice bonus is calculated automatically by CMS. It’s even better than the complex patients bonus however, because any practice with 15 or fewer MIPS-eligible providers will get the full 5 points (either individually or as a group depending on how they report). With the complex patients bonus, you won’t know how many of the 5 possible points you’ll earn until after the 2018 performance year is over.
All scores will be relative

One of the most difficult aspects of MIPS is that your payment adjustments will be affected by how the healthcare industry as a whole responds to MIPS every year. If many eligible providers choose to ignore MIPS or only offer minimal participation, those who do more in 2018, but still fall short of the 70-point exceptional performance threshold, will see a higher positive adjustment up to the maximum of 5% for 2020.

If many eligible providers overachieve on MIPS in 2018, and the number of providers with a final score of 70 or more is high, then even a score of 70 could yield only a small positive adjustment. Remember, the $500 million exceptional performance money must be shared between all providers who reach or exceed the 70-point threshold, though CMS has committed to a minimum of a 0.5% additional positive adjustment just for hitting 70 points (the $500 million will be distributed as positive Medicare payment adjustments rather than flat dollar amounts).

Thus doing more will always give you the best chance of more payments, but MIPS may reach a point where even significant participation will yield only minor positive adjustments. The program is still so new that participation data is scant.

Author: Grant Huang (ghuang@drsmgmt.com)