2019 is the third year for the Quality Payment Program (QPP). Most radiation oncologists will participate in the Merit-based Incentive Payment System (MIPS). Based on an eligible clinician’s performance in four categories in 2019, their 2021 Medicare Part B reimbursement will be impacted.
In preparation for MIPS, you need to answer the following questions:
Physicians can look up eligibility on the QPP Participation Lookup tool based on their National Provider Identification (NPI) number.
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 AND more than 200 Medicare Part B covered services. Billing and patient volumes are based on 12-month historical data (September-August). The new requirements allow for physicians to opt-in to MIPS if they meet at least 1 of the 3 criteria. Those opting in will receive the related payment adjustment 2 years later. Those that do NOT meet any of the criteria can voluntarily report data; however, they will not receive a payment adjustment.
Eligible clinicians include:
There are many requirements and rules in MIPS, however there is still a large amount of flexibility for participating in the program.
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 30 points to avoid the 7 percent penalty or achieve more points to receive a larger payment adjustment. 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 75 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.
As the Performance Threshold increases year to year, it is harder to avoid the penalty. In 2019, practices must submit data from more than one performance category to achieve 30 points.
A single NPI tied to a single TIN
A single TIN. All NPIs who have assigned their billing rights to a single TIN would be part of this group
A physician or group of less than 10 that has joined with another similar group (regardless of specialty)
Impact on Payment Adjustment
Your performance will directly impact your payment adjustment
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
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
MIPS provides several data submission options, and most are available for Quality, Improvement Activities and the Promoting Interoperability performance categories. Beginning in 2019, data can be submitted via multiple mechanisms within a performance category. For example, a physician can utilize a registry to report some quality measures and claims to report others. If the same measure is submitted via multiple mechanisms, the one with the greatest number of measure achievement points will be selected for scoring.
In 2019, only small practices (≤15 eligible clinicians) can use Claims for data submission. It’s not an option if you’re participating in MIPS as a large 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. Each registry is different; however, most will collect data for the Quality, Improvement Activities and Promoting Interoperability performance categories. A full list of CMS-approved entities can be found on the CMS website.
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 2019 measures. The QOPI Reporting Registry collects and reports 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.
An eligible clinician or group’s overall payment adjustment is based on the Composite Performance Score (CPS). For 2019, the CPS score is based on four performance categories: Quality, Promoting Interoperability, Improvement Activities and Cost.
Clinicians must report either six measures or the three in the Radiation Oncology measure set. In prior years there were four in the measure set, however, CMS removed the Dose Limits to Normal Tissue measure from MIPS due to its high-performance rate.
As a reminder, physicians must submit data on 60 percent of all patients (regardless of payer) that meet the measure’s denominator criteria for a full year. The only exception to this requirement is for measures reported via claims, in which case, physicians must submit data on 60 percent of all Medicare Part B patients that meet the measure’s denominator during the reporting period.
To earn achievement points, physicians need to submit a minimum of 20 cases per measure and a measure benchmark must exist. If a benchmark was not available from historical data, CMS will attempt to calculate benchmarks based on 2019 performance data.
If a physician submits less than 20 cases for a measure or a measure does not have a benchmark, no achievement points will be awarded, and the physician will only receive the three baseline points for that measure.
There are three bonus point opportunities in the Quality category. Bonus points will be added to a clinician’s overall Quality performance category points.
Small Practice Bonus
Total Available Measure Points
The total available measure points will be 30 or 60 depending on whether you report the three measures in the radiation oncology measure set or six independent quality measures.
The improvement score can only be awarded if a physician or practice has participated in the program for two consecutive years and is awarded based on performance in the Quality category compared to the previous MIPS performance period. To allow flexibility for physicians and practices to choose different measures from year to year, the improvement score is based on the overall Quality score instead of the performance on specific measures.
If a MIPS eligible clinician has a previous year Quality score less than or equal to 30 percent, CMS will compare 2019 performance to an assumed 2018 Quality performance category score of 30 percent.
Improvement Score = (2019 Quality Score - 2018 Quality Score) x10
2018 Quality Score
The improvement score cannot be negative, meaning that a practice that did not have an increase in performance would receive zero improvement points.
Beginning in 2019, clinicians that furnish 75 percent or more of their covered professional services in POS 21, 22 or 23, and have at least a single service billed with POS 21 (inpatient hospital) or 23 (emergency room) can use the Quality and Cost scores with the facility’s Value-Based Purchasing score. Practices will still need to report on the Improvement Activities and Promoting Interoperability category separately.
If an eligible physician furnishes more than 75 percent of their covered professional services in an on-campus hospital (POS 22), then CMS will consider them exempt from PI. CMS makes this determination based on claims data for a period prior to the performance year. The hospital-based designation can be found on the MIPS eligibility status. You will not need to request an exemption.
For physicians practicing in free-standing centers, you can apply for an exemption because of hardships, including:
To receive the hardship exemption, physicians need to submit an application& explaining why the EHR technology is not available. The application is typically released in Summer of the performance year.
If exempt, this category weight is reduced to 0 percent and redistributed to the Quality performance category. Despite the exemption, eligible physicians who want to pursue reporting PI measures can still report and get credit.
This performance category has been reworked in 2019 to align with other federal payment systems.
For 2019 PI, eligible practices must use 2015 Edition Certified Electronic Health Records Technology to complete reporting. The complete list of certified systems and modules can be found on the ONC website.
CMS finalized the following measures that are required for all clinicians.
Many radiation oncology practices already report to a clinical data registry, but the National Institutes of Health has compliled a list that might help identify new registries.
There are over one hundred activities to choose from in 2019. How activities are weighted is an important factor in determining the score and how best to satisfy the minimum requirements. For a full list of the activities, visit CMS’s QPP website.
While only attestation of activity completion is necessary for reporting, practices should maintain documentation to demonstrate consistent and meaningful engagement within the performance period. In the event of an audit, documentation must be presented.
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). There is no fee to participate in RO-ILS, but the facility must sign an agreement with Clarity PSO so start the contracting process now. Join the more than 400 facilities enrolled in RO-ILS.
For this 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 firstname.lastname@example.org 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).
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 15 improvement activities. One of these activities is participation in MOC Part IV, which can be accomplished with the APEx MOC template. The self-assessment component of the program can satisfy all the requirements for the Improvement Activities performance category.
The Medicare Spending per Beneficiary (MSPB) cost measure assesses the cost to Medicare of services performed by an individual clinician during an MSPB episode. An MSPB episode includes all Medicare Part A and Part B claims falling in the episode “window,” which begins three days prior to a hospital admission and ends 30 days after the patient is discharged from the hospital.
Episodes will be attributed to the clinician who provided the Part A and Part B services to a beneficiary during the admission.
Based on CMS’ calculations for this measure, we believe it could be likely that large radiation oncology practices, submitted as a group, could have the necessary patient counts for this measure in 2018.
The Total per capita cost measure evaluates the overall cost of care provided to beneficiaries attributed to clinicians, as identified by a unique Taxpayer Identification Number/National Provider Identifier (TIN-NPI). The Total Per Capita Costs for All Attributed Beneficiaries measure can be reported at the TIN or the TIN-NPI level.