MIPS survival guide 2019: Doing the bare minimum for a 0% update
The third year of Medicare’s Merit-based Incentive Payment System (MIPS) is now well underway, and it’s gotten tougher to skate through the year doing the bare minimum to avoid a Part B pay cut in 2021.
This is by design, as MIPS was crafted via legislation to phase in tougher and tougher reporting requirements over the course of six years, beginning with the 2017 performance year. This year’s reporting has the ability to shift 2021 Part B payments anywhere f rom -7% to +7%, though the exact size of positive payment adjustments will depend on how high the scores are for all providers who participate with MIPS this year. This is due to the requirement that MIPS remain a budget-neutral program, such that a larger number of high performers will reduce the amount of bonus payments each individual high performer receives.
In this article we’ll review the changes to MIPS from 2018 to 2019 and then cover the available options to meet the minimum reporting requirements to ensure a 0% Medicare Part B payment update in 2021. In the next issue of The ENT Voice, we will discuss 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.
New provider types for MIPS: Note that in 2019, several additional provider types are now MIPS-eligible, so they must begin MIPS reporting for the first time. These include physical and occupational therapists, qualified speech-language pathologists, clinical psychologists, registered dietitian or nutrition professionals, and of particular interest for ENT groups, qualified audiologists.
Check your eligibility, yet again: In 2019, CMS has further expanded its “low-volume” threshold for MIPS eligibility, which allows providers to be exempt from MIPS reporting, and any MIPS-associated payment adjustments. There are now three types of low-volume threshold exemptions: allowed charges, total beneficiaries seen, and total number of covered professional services performed, all counted based on a 12-month MIPS “determination period” from Oct. 1, 2017 to Sept. 30, 2018, including a 30-day claims run out.
For an individual provider, the charges threshold is $90,000 or less in Part B allowed charges for professional services over the determination period. The beneficiary threshold is 200 or fewer Part B beneficiaries seen over the period. Finally, the new threshold for 2019 is based on number of covered services, which is 200 or fewer covered professional services over the period. CMS determines whether any of these apply and you can check the 2019 MIPS eligibility status of any specific provider by visiting this CMS website and entering in the provider’s national provider identifier (NPI).
2019 MIPS: Getting by with the bare minimum
To avoid a payment penalty of up to -7% in 2021, providers who are MIPS-eligible (aka required to participate) must earn a MIPS composite score of at least 30 points, double the 2018 minimum of 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. The weighting has changed slightly in 2019 and is mandated to shift each year of the program, with later years emphasizing the Cost Performance category.
The four categories and their 2019 weights (as in, percent of the composite score) are:
- Quality Performance, weighted at 45%, comprising most of the quality reporting measures.
- Promoting Interoperability, weighted at 25%, formerly known as Advancing Care Information, and before that, it was essentially Medicare’s EHR meaningful use program.
- Improvement Activities, weighted 15%, formerly known as Clinical Improvement Activities, consisting of a variety of steps aimed at improving patient access, experience and outcomes.
- Cost Performance, weighted at 15%, up from a 10% weight in 2018, and not counted toward the MIPS score in 2017. This is the only MIPS category that CMS calculates automatically without needing providers to submit data.
Based on these weights for 2019, you have more options to hit 30 points efficiently whereas earlier years the best way to hit the minimum was to report several Quality Performance measures, when that category was worth as much as 60% of the final score. Here’s a few of the quickest ways:
- Full participation in the Quality Performance category would yield 45 points, getting you over the 30-point hump immediately. Partial participation in Quality Performance could yield 30 points as well. Full participation is accomplished by reporting a total of six quality measures to CMS, of which at least one must be an “outcome” measure such as Surgical Site Infection (percent of patients 18 and older who have a surgical site infection). Most outcomes measures won’t be applicable to ENT providers, though ENT surgeons who perform head and neck surgeries may find some applicable outcomes measures. If you can’t find an outcomes measure that makes sense, CMS allows you to report a non-outcome but high-priority quality measure, such as Acute Otitis Externa, Topical Therapy (percent of patients 2 and older with acute otitis externa who were prescribed topical preparations). View the 2019 quality measures list here.
- It is possible to hit 30 points with just four quality measures, and keep in mind that measures marked “high priority” yield more points under the Quality Performance category than other measures.
- Full participation in the Promoting Interoperability Performance category gets you 25 points, just short of the minimum requirement, but you can combine this with minimal participation in the Improvement Activities Performance category to hit 30 points (or you may get 5 bonus points for being a small practice, see below).
- This category is simplified in 2019, with 39 possible measures to report across four objectives (e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange). You would need to report a total of six measures to hit the full score for this performance category – view the 2019 Promoting Interoperability measures list here.
- Note that the Promoting Interoperability Performance category requires you to have an EHR system that is certified under the 2015 Edition CEHRT rules. You can search the federal Certified Health IT Product List (CHPL) website to see if your EHR system has hit the 2015 standard.
Bonuses for complex patients and small practices
Two sources of bonus points are available in 2019, carried over from 2018: treatment of “complex” patients and bonus points for qualifying as a “small practice.” Here’s how they work.
- Complex patients bonus, determined by 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, determined automatically by CMS. This bonus adds up to 5 points toward the MIPS composite score and is 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).
While you can’t necessarily count on getting 5 bonus points for complex patients (the methodology of converting ICD-10 codes to HCC risk scores is complex and not completely explained by CMS), if you have 15 or fewer MIPS-eligible providers in your practice, you can bank on having 5 bonus points and therefore a minimum MIPS score target of 25 points. This would allow you to skip the Quality Performance category and just fully participate with the Promoting Interoperability category. Look for a guide to maximizing your composite score and earning as much bonus payments as possible under MIPS in a future issue of The Business of Medicine.