Eligibility
Inclusion
MIPS applies to clinicians billing more than $90,000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare Part B enrolled patients a year. Billing and patient volumes are based on 12-month historical data (September-August). This is an increased threshold from the 2017 performance year which will reduce the number of eligible clinicians.
Eligible clinicians include:
- Physicians
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
Exclusion
It is also important to know who is exempt from MIPS. Exempt individuals and groups do not need to participate in this program and will not be subject to any positive or negative payment adjustment.
- Clinicians below the low-volume threshold: Medicare Part B charges less than $90,000 a year OR seeing fewer than 200 beneficiaries in that same year. If one of the two criteria are met, the clinician is considered to meet the low-volume threshold and thereby is exempt from MIPS.
- Clinicians who participate in Advanced Alternative Payment Models as “Qualified Participants”.
- Clinicians that are newly enrolled in Medicare.
Notification
Similar to the 2017 program, CMS provides eligibility and special designations on the existing QPP website. Physicians can look up eligibility based on their National Provider Identification (NPI) number. Information will include CMS’ analysis of the number of Tax Identification Numbers (TINs) associated with your NPI, eligibility, hospital-based designation (more than 75 percent of services are billed at the hospital), and small practice designation (15 or less eligible clinicians). This information will be provided for both the individual (NPI) and group-level (TIN). This is a valuable resource to determine clinician specific program requirements, as well as ensure that CMS has the correct information regarding your practice.
Please note, clinicians treating patients under multiple TINs may have different eligibilities for each of their TIN/NPI combinations.
Bonus Points
Aside from bonus options within each performance category, the 2018 performance year introduces two main bonus opportunities that will be applied to the final Composite Performance Score (CPS):
- Small Practice Bonus – 5 points - Practices comprised of 15 or less eligible clinicians, including solo practices, will automatically receive this bonus
- Complex Patient Bonus – up to 5 points – CMS will automatically calculate and award this bonus based on two indicators:
- Medical complexity as measured through Hierarchical Condition Category (HCC) risk scores*, and
- Social risk as measured through the proportion of patients with dual eligible† status.
The bonus will be calculated by adding the HCC Score, capped at 3-points, and the dual eligible ratio, multiplied by 5. You do not need to submit any additional information for CMS to be awarded this bonus.
*HCC Risk Score is a payment methodology based on risk used by CMS to adjust payments at the patient level. This means that 2 patients within the same community can have a different payment rate based on several factors relating primarily to the amount of risk—or work—it takes to maintain the health of a patient. In the 2018 QPP proposed rule, CMS stated that the average HCC score for radiation oncology is 1.79.
†Dual Eligible refers to beneficiaries qualifying for both Medicare and Medicaid benefits. CMS has stated that the average dual eligible ratio for radiation oncology is 22.20%
Sample Calculations
General Equation: HCC + (Dual Eligible Ratio x 5) = Complex Patient Bonus
Using CMS radiation oncology averages: 1.79 + (0.22 x 5) = 2.89 Complex Patient Bonus Points
Each practice will have its own unique combination of indicators based on the population it serves and are capped at 5 points.
Participation
There are many requirements and rules in MIPS, however there is still a large amount of flexibility for participating in the program:
- Program goals
- Individual vs. Group vs. Virtual Group Reporting
Program Goals
The level of participation in the MIPS program is dependent on the practice’s financial goals. There is a different level of effort if a practice wants to achieve 15 CPS points to avoid the 5 percent penalty or achieve more CPS points to receive a bonus. In this budget-neutral program, the funds collected from the penalties will be utilized to pay for the positive payment adjustments. If an individual or group achieves over 70 CPS points, they will be eligible for the exceptional performance bonus, funded through a separate source. Having a goal in mind prior to determining the remainder of the participation elements is key.
Any of the following options meet at least 15 points for a solo physician or small practice (≤15 eligible clinicians):
- Improvement Activities:
- 2 medium weight + Small Practice Bonus = 20 CPS
- 1 high weight + Small Practice Bonus = 20 CPS
- Promoting Interoperability:
- Base measures + Small Practice Bonus = 17.5 CPS
- Quality:
- Options are dependent on too many variables to list
Any of the following options meet at least 15 points for a large practice (>15 eligible clinicians):
- Improvement Activities:
- 4 medium weight = 15 CPS
- 2 high weight = 15 CPS
- 2 medium weight + 1 high weight = 15 CPS
- Promoting Interoperability:
- Base measures + Performance = Variable CPS depending on performance score
- Base measures + Bonus points = 22.5 CPS
- Quality:
- Options are dependent on too many variables to list
A combination of CPS points from different performance categories is also an option to avoid the penalty.
Individual vs Group vs Virtual Group
There are three reporting options for MIPS based on TIN/NPI combination – individual and group reporting, as well as a new reporting option for 2018,
Virtual Groups.
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Individual
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Group
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Virtual Group
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Definition
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A single NPI tied to a single TIN
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A single TIN. All NPIs who have assigned their billing rights to a single TIN would be part of this group.
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A physician or group of less than 10 that has joined with another similar group (regardless of specialty)
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Impact on Payment Adjustment
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Your performance will directly impact your payment adjustment
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A group’s performance is assessed across all of the MIPS performance categories and the group will get one payment adjustment based on the group’s performance
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A Virtual Group’s performance is assessed across all of the MIPS performance categories and the virtual group will get one payment adjustment based on the virtual group’s performance
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Data submission options
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EHR, registry, QCDR*, claims
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Web interface (only for groups with 25 or more clinicians); EHR, registry, QCDR
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Web interface (only for virtual groups with 25 or more clinicians), EHR, registry, QCDR
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CMS Registration
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None
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None, unless the group is utilizing the Web Interface for reporting, in which case they must register with CMS by June 30, 2018.
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To participate as a virtual group, a contract between the participating physicians/practices must be established. The virtual group must register with CMS by December 31, 2017.
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*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.”
The decision to report as an individual, group, or virtual group is part of your MIPS strategy and will be unique to your practice.
Performance Categories
An eligible clinician or group’s overall payment adjustment is based on the Composite Performance Score (CPS). For 2018, the CPS score is based on four performance categories: Quality, Promoting Interoperability, Improvement Activities and Cost.
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The “Quality” performance category typically comprises 50 percent of the CPS. Clinicians can select from approximately 275 measures that have been approved for the MIPS program, including the four measures in the radiation oncology measures measure set. Six quality measures are required unless your practice chooses to report the entire radiation oncology measure set. Data completeness rules for 2018 require a full year of reporting and at least 60 percent of patients that meet the measure’s denominator criteria, regardless of payer, with a minimum of 20 cases.
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The “Promoting Interoperability" (PI) performance category, recently known as the Advancing Care Information, typically comprises 25 percent of the CPS. Depending on whether an individual or group uses 2014 or 2015 certified EHR technology (CEHRT), clinicians need to report on all “base” measures and can choose to select additional performance and bonus measures to achieve a higher score. Hospital-based clinicians are exempt from this category and non-hospital based clinicians can apply for a hardship exemption based on certain criteria. An exemption or hardship reduces the PI category to zero and increases the Quality category weight from 50 to 75 percent. In 2018, a practice can achieve bonus points if they utilize 2015 CEHRT for all reporting.
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The “Improvement Activities” (IA) performance category comprises 15 percent of the CPS. Clinicians can select from 114 improvement activities, including 21 that are new in 2018. 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 and size. Clinicians simply need to attest to completing the activities. RO-ILS and APEx can help satisfy the IA category.
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The Cost performance category typically comprises 10 percent of the CPS weight in 2018. There are currently two cost measures in the performance category: Medicare Spending Per Beneficiary (MSPB) and total cost per capita. Providers will not need to report any data, as CMS will use administrative claims data to attribute patients and costs to providers. For 2017, CMS collected cost data and will provide feedback to clinicians by July 1, 2018, but CMS did not incorporate performance in this category in the 2017 program year (i.e., 2019 payment adjustment). 2018 is the first year of the MIPS program that the Cost performance will be included in the overall MIPS CPS. If CMS cannot calculate a cost score for a physician/group, then the Cost category is reduced to zero and the weight of the Quality category increases from 50 to 60 percent
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Data Submission
MIPS provides a number of data submission options and most are available for Quality, Improvement Activities and the Promoting Interoperability performance categories. While a physician may use more than one mechanism for different performance categories, only one may be used within a performance category. For example, a physician can utilize claims to report the Quality performance category and the CMS Attestation Portal for Promoting Interoperability and Improvement Activities.
You can only use Claims data submission if you’re reporting as an individual MIPS eligible clinician to submit quality data. It’s not an option if you’re participating in MIPS as a group. Claims data is only available for the Quality performance category. If you choose to submit quality data through claims, Quality Data Codes (QDCs) will need to be added to denominator eligible claims to show that the required quality action occurred or exclusion applied. QDCs are specified Current Procedure Terminology (CPT) II codes (with or without modifiers) and G-codes used for submission of quality data for MIPS. When these codes are included on your claims form, it identifies your selected quality measures for CMS. You’ll also need to apply encounter codes, including ICD-10-CM, CPT Category I, or Healthcare Common Procedure Coding System (HCPCS) codes. These codes show which patients should be added toward the denominator/numerator of the quality measure.
A Registry is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. An example of this is the MIPSWizard, similar to the PQRSWizard, that allows physicians or groups to enter data manually. Each registry is different; however, most will collect data for the Quality, Improvement Activities and Promoting Interoperability performance categories.
A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. The QCDR reporting option is different from a Registry because it is not limited to quality measures within MIPS. The QCDR can develop and submit QCDR measures for CMS consideration and approval. The QOPI Reporting Registry is available for radiation oncology and medical oncology practices. See a full list of the 2018 measures. Each QCDR is different; however, most will collect data for the Quality, Improvement Activities and Promoting Interoperability performance categories.
An Electronic Health Record (EHR) can provide two ways to submit data to CMS. Either the vendor can submit MIPS data to CMS on your behalf or the vendor can provide the clinician with a Quality Reporting Document Architecture (QRDA) file which you can submit on your own through the CMS Portal. The capability and available options are vendor specific, so please check with your EHR vendor to understand the available options. CMS approves EHR data submission for Quality, Improvement Activities and Promoting Interoperability performance categories.
The CMS Portal is a secure internet-based data submission mechanism available for all physicians and groups. To sign into the CMS portal, you will need your Enterprise Identity Management (EIDM) credentials and have the appropriate user role associated with your organization. The EIDM login is the same login used during PQRS submission. Password reminders and registration for new users can be found on the QPP webpage. You will be able to report as either a group or individual for each TIN associated with the account. Attestation is available for the Improvement Activities and Promoting Interoperability performance categories. For the Quality performance category, users will be able to import an approved data file.
The CMS Web Interface is a secure internet-based quality data submission mechanism available only for groups of 25 or more MIPS-eligible clinicians who register prior to the June 30, 2018 deadline. When you choose to submit data through the CMS Web Interface, you’re agreeing to report on all 15 CMS Web Interface general medicine quality measures for a full calendar year (January 1-December 31). The Web Interface is interconnected with the CMS Portal for reporting Improvement Activities and Promoting Interoperability performance categories.
Application of Payment Adjustments
The MIPS score follows the NPI in all cases; therefore a clinician will receive reimbursement in 2020 based on 2018 performance regardless of their TIN in 2020. CMS is aware that there are unique professional situations that occur during a performance year and has itemized a few common scenarios:
For clinicians who submit data as a part of a group AND individually, CMS will take the highest final score between those two scores and apply the MIPS payment adjustment. CMS has presented specific examples to help explain this further.
If a clinician billed Medicare Part B charges under more than one group (TIN) during the performance period, the clinician is required to participate in MIPS for each TIN association. For clinicians associated with multiple TINs, the clinician will either report at the individual level if the group elects to report at the individual level or be included in the group-level reporting if the group elects to report at the group level. Such clinicians will be assessed and scored for each associated TIN/NPI combination and receive a MIPS payment adjustment for each associated TIN/NPI combination.
In the case where a MIPS eligible clinician starts working in a new practice or otherwise establishes a new TIN that did not exist during the performance period, there would be no corresponding historical performance information or final score for the new TIN/NPI. If there is not a final score associated with a TIN/NPI from the performance period, CMS will use the NPI’s performance for the TIN(s) the NPI was billing under during the performance period.
If a clinician worked in one practice (TIN A) in the performance period, but is working at a new practice (TIN B) during the payment year, then CMS will use the final score for the old practice (TIN A/NPI) to apply the MIPS payment adjustment for the NPI in the new practice (TIN B/NPI).
If a clinician billed under more than one TIN during the performance period, and the clinician starts working in a new practice or otherwise establishes a new TIN that did not exist during the performance period, CMS will take the highest final score associated with the NPI in the performance year.
Any individual (NPI) included in the TIN who is excluded from MIPS because they are identified as a new Medicare-enrolled clinician, a QP or Partial QP, or does not exceed the low-volume threshold would not receive a MIPS payment adjustment, regardless of their MIPS participation.
ASTRO Products for Success
Utilize three ASTRO programs to meet the Improvement Activities performance category requirements and consider submitting all the performance category data via the QOPI Reporting Registry.
QOPI Reporting Registry
Quality Oncology Practice Initiative (QOPI®) Reporting Registry brought to you by ASCO and ASTRO is now available! This Qualified Clinical Data Registry (QCDR) can be utilized to report all of the MIPS performance categories.
QOPI Reporting Registry is a beneficial tool that drives quality improvement without adding burden to practices. FIGmd, the experienced technology firm supporting the QOPI Reporting Registry, developed a process to extract data from electronic health records (EHR). It also offers a manual data entry option. With the QCDR designation from CMS, the QOPI Reporting Registry can create additional quality measures not currently available in federal reporting programs and therefore offers more flexibility than qualified registries. See the full list of 2018 measures.
The QOPI Reporting Registry costs $495 per physician to collect data, provide a quality assurance dashboard and submit MIPS data to CMS. For more information, please contact the QOPI helpdesk.
RO-ILS
RO-ILS: Radiation Oncology Incident Learning System, sponsored by ASTRO and AAPM, is part of Clarity PSO, a federally listed patient safety organization. A medium weighted activity within the “Improvement Activities” (IA) performance category is “Participation in an AHRQ-listed patient safety organization” (Activity ID = IA_PSPA_1). There is no fee to participate in RO-ILS, but the facility must contract with Clarity PSO, so start the contracting process now for participation to apply for the 2018 performance year.
While only attestation of activity completion is necessary for reporting, be sure to maintain documentation to demonstrate consistent and meaningful engagement within the period for which you are attesting. In the event of an audit, documentation must be presented.
For this particular activity, CMS suggests "documentation from an AHRQ-listed patient safety organization (PSO) confirming the eligible clinician or group's participation with the PSO." Therefore, upon request, Clarity PSO will send a Letter of Participation stating that your practice or facility is actively participating in RO-ILS during the reporting period. Please email radoncsupport@claritygrp.com to request a RO-ILS Letter of Participation. Letters will be sent later in the year.
Additionally, you can use RO-ILS towards fulfilling the Part IV Physician Quality Improvement (PQI) Maintenance of Certification (MOC) requirements established by the American Board of Radiology. This meets an additional medium-weighted improvement activity (Activity ID = IA_PSPA_2).
APEx
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 over 15 improvement activities. One of the activities is participation in MOC Part IV, which can be accomplished with the APEx MOC template.
In the event of an audit, proof of completion of each activity needs to be maintained. The APEx MIPS IA Table includes CMS recommended documentation as well as the mapped APEx Standard.