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2017 is the inaugural year for the Quality Payment Program (QPP). Most radiation oncologists will participate in the Merit-based Incentive Payment System (MIPS) program. MIPS replaces and consolidates previous Medicare quality initiatives (Physician Quality Reporting System (PQRS), Value-based Modifier (VM) and EHR Incentive (Meaningful Use) Program) into one comprehensive program. Based on an eligible clinician’s performance in three categories in 2017, their 2019 Medicare Part B reimbursement will be impacted. Since MIPS is a new program, 2017 is a transition year with an option to “Pick Your Pace”.
In preparation for MIPS, you need to answer the following questions:
MIPS applies to clinicians billing more than $30,000 a year in Medicare Part B allowed charges AND providing care for more than 100 Medicare Part B enrolled patients a year. Billing and patient volumes are based on 12-month historical data (September-August).
Eligible clinicians include:
It is also important to know who is exempt from MIPS.
Exempt individuals may volunteer to report in MIPS, but they will not be eligible for any pay adjustments.
The eligibility calculation is complicated, and CMS will notify clinicians the status of their eligibility. CMS is also building a website to look up eligibility based on Tax Identification Number (TIN) / National Provider Identification (NPI) combination. The website has not yet been released, and ASTRO will update this webpage with the CMS link when available. Please note, physicians treating patients under multiple TINs will receive an eligibility notice under each TIN.
There are two reporting options for MIPS based on TIN/NPI combination – individual and group.
A single NPI tied to a single TIN
Two or more clinicians who have assigned their billing rights to a single TIN
Impact on Payment Adjustment
Your performance will directly impact your payment adjustment
Groups’ performance is assessed across all of the MIPS performance categories and the group will get one payment adjustment based on the group’s performance
Data submission options
EHR, registry, QCDR*, claims
Web interface (requires group registration by June 30, 2017), EHR, registry, QCDR
*A qualified clinical data registry (QCDR) is “a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.”
We expect most radiation oncologists to report as groups; however, the decision to report as an individual or group should play a role in your MIPS strategy.
MIPS will base an eligible clinician or group’s overall payment adjustment on the Composite Performance Score (CPS). For 2017, the CPS score is based on three performance categories: Quality, Advancing Care Information and Improvement Activities.
The “Quality” performance category comprises 60 percent of the CPS and is a new iteration of the Physician Quality Reporting System (PQRS). Clinicians can select from approximately 275 measures that have been approved for the MIPS program, including four radiation oncology measures. The number of measures required and length of reporting depends on which pace you select. For the Partial Participation and Full Participation pace options, you need to report on at least 50 percent of patients that meet the measure’s denominator criteria, regardless of payer. The radiation oncology specialty measures set includes:
The “Advancing Care Information” (ACI) performance category comprises 25 percent of the CPS and is a new iteration of the EHR Incentive (Meaningful Use) program. Depending on whether an individual or group uses 2014 or 2015 certified EHR technology, clinicians need to report on all “base” measures and select additional measures. Hospital-based clinicians are exempt from this category and clinicians can apply for a hardship exemption. An exemption reduces the ACI category to zero and increases the Quality category weight to 85 percent.
The “Improvement Activities” (IA) performance category comprises 15 percent of the CPS and does not have a Medicare program predecessor. Clinicians can select from approximately 90 improvement activities approved for the MIPS program. All activities are weighted as medium, worth 10 points, or high, worth 20 points. Clinicians must complete activities for at least 90 consecutive days. The number of activities/points needed depends on practice location, size and the pace you select. For 2017, clinicians simply need to attest to completing the activities. RO-ILS and APEx can help satisfy the IA category.
In future years of the program, MIPS will include a fourth “Cost” performance category, similar to the previous Value-Based Modifier program. For 2017, CMS will collect cost data and provide feedback to clinicians but will not incorporate performance in this category in the 2019 payment adjustment. Providers will not need to report any data for this category, as CMS will use administrative claims data to attribute patients and costs to radiation oncologists.
To allow for more flexibility during the 2017 transition year, CMS is allowing clinicians in MIPS to “Pick Your Pace”. While it may benefit providers to gain experience participating in all aspects of MIPS for success in future years, in 2017, eligible clinicians can choose one of four options:
The following table summarizes the pace options and an overview of the reporting requirements for each performance category.
The MIPS Pace table summarizes the pace options and an overview of the reporting requirements for each performance category. Click on the image to the right to view in full size.
The first performance year for MIPS is 2017, and technically started January 1. However, there is some flexibility in the start date based on your selected pace. Regardless of your pace, the performance period ends on December 31, but CMS will accept 2017 performance data until March 31, 2018.
In Fall 2018, CMS will provide feedback on performance. The first payment adjustment for MIPS Program will occur in 2019. It is important to note there is a two-year lag from your performance reporting to its impact on your payment.
Figure courtesy of CMS
2015 Medicare Program(s) Performance Period Payment adjustments based on 2015 performance in PQRS, VBM and MU begin Spring 2017.
2016 Medicare Program(s) Performance PeriodPayment adjustments based on 2016 performance in PQRS, VBM and MU begin Spring 2018.
2017 MIPS Performance Period
2018 MIPS Performance Period
Utilize two ASTRO programs to meet the Improvement Activity performance category requirements and consider submitting the Quality performance category measures via the new MIPSwizard.
RO-ILS: Radiation Oncology Incident Learning System, sponsored by ASTRO and AAPM, is a part of Clarity PSO, a federally listed patient safety organization. A medium weighted activity within the “Improvement Activity” (IA) performance category is “Participation in an AHRQ-listed patient safety organization” (Activity ID = IA_PSPA_1). Participating in RO-ILS automatically satisfies the “Test: Improvement Activities” option within “Pick Your Pace,” so 2017 RO-ILS participants will likely avoid a negative adjustment in 2019. There is no fee to participate in RO-ILS, but the facility must contract with Clarity PSO so start the contracting process now. Join the more than 250 RO-ILS facilities today and check off your minimum 2017 MIPS requirement!
In the event of an audit, ASTRO recommends maintaining proper documentation of RO-ILS involvement. Options include:
ASTRO’s Accreditation Program for Excellence (APEx) focuses on a culture of quality and safety, as well as patient-centered care. Evidence indicators required for APEx accreditation map to 17 improvement activities. The self-assessment component of the program can satisfy all the requirements for the Improvement Activities performance category.
In the event of an audit, proof of completion of the following can serve as documentation:
ASTRO’s MIPSwizard is a CMS-qualified registry that collects and reports data to CMS. This easy-to-use online tool provides:
The MIPSwizard will be available later this year, ASTRO will announce when it is released.
To determine what MIPS scenario you most likely fall into, select the entity below that bills your physician services.
There are multiple paths to MIPS participation. In addition to the various “Pick Your Pace” options, there are additional nuances on MIPS participation based on how your Medicare billing is structured.
As a reminder, a National Provider Identifier (NPI) is used for identification purposes while a Taxpayer Identification Number (TIN) is used for tax purposes. All physicians have an NPI number. Depending on employment contracts, a clinician may have:
In the first situation, the hospital or physician group bills both the professional component (PC), which covers the work done by the physician directly, and the technical component (TC), which covers the cost of the equipment, supplies and the work done by medical physicists and/or specialized support staff, such as radiation therapists.
In the second situation, the physician bills for the PC while the entity (e.g., hospital) bills for the TC. Physicians in this clinical setting would add a “-26” modifier indicating that they only provided the professional component for a particular service.
Last Updated March 1, 2017
As always, each radiation oncology practice and its eligible clinicians are encouraged to review primary materials (statutes, regulations, agency interpretive guidance, etc.) and seek appropriate legal or other professional guidance for a comprehensive understanding of their obligations. The information on this website should not be construed as legal, coding or other professional advice, and ASTRO assumes no liability for the information contained herein.
For more information, contact:
Ksenija KapetanovicQuality Improvement Manager703-286-1604