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 6 measures or the three in the Radiation Oncology measure set. In prior years there were 4 in the measure set, however, CMS removed the Dose Limits to Normal Tissue measure from MIPS due to its high-performance rate.
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.
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.
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.