*High priority measures are those categorized as outcome, appropriate use, patient safety, efficiency, patient experience, and care coordination.

Aside from the specialty measure set, there are other MIPS quality measures that could potentially be reported by a radiation oncology practice, shown in this curated list.

Overview

The following equation can be utilized to calculate the quality score:

The details of the measure points, bonus points, and total possible points are described below. The Quality score cannot exceed 100 percent.

The following equation can be utilized to calculate the quality category points awarded towards the composite performance score (CPS):

Quality Points towards CPS = (Quality Score + Improvement Score) x (Category Weight)

The improvement score is discussed in detail below. The category weight of the performance category can vary from 50 percent to 85 percent depending on whether the physician is exempt from Promoting Interoperability (PI) and/or whether cost measure can be calculated for the physician.

Measure Points

Each measure will receive a total score from 0 to 10 points based on reporting and performance.

• 0 points will be awarded if no data is submitted.
• 1 baseline “reporting” point will automatically be awarded if any data is submitted for a large practice.
• 2 to 9 additional achievement points will be added to the 1 baseline point based on a practice’s performance against a benchmark, but only if the data completeness requirements are met.

As a reminder, practices 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, groups 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, practices 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 2018 performance data. 

If a practice submits less than 20 cases for a measure or a measure does not have a benchmark, only 2 achievement points will be awarded and the practice will only receive the three baseline points for that measure.

Review the 2018  Radiation Oncology Measures Set Benchmarks.  

For more information about benchmarks, review CMS's Benchmark Overview. 

Bonus Points

There are two ways to receive bonus points in the Quality category. Bonus points will be added to a clinician’s overall Quality performance category points.

• End-to-end reporting -  One bonus point if quality data is reported directly from an EHR to a qualified registry, QCDR, or via the CMS Web Interface.
• Additional measures –
  • One bonus point for each additional high priority measure.
  • Two bonus points for each additional outcome and patient experience measure.
   

Total Available Measure Points

The total available measure points will be 40 or 60 depending on whether you report the 4 measures in the radiation oncology measure set or 6 independent quality measures.

Improvement Score

Starting in 2018, CMS finalized the addition of an “improvement score” in the Quality performance category based on the previous MIPS performance period.  To allow flexibility for practices to choose different measures from year to year, the improvement score will be based on the overall quality score instead of the performance on specific measures.

The improvement score can only be awarded if a practice has participated in the program for two consecutive years.  However, CMS has made some accommodations to account for the Pick Your Pace transition options in 2017. If a practice has a previous year Quality score less than or equal to 30 percent, CMS will compare 2018 performance to an assumed 2017 Quality performance category score of 30 percent.  This modification allows practices that chose the test pace in 2017 to still be eligible for the improvement score in 2018.

For example, if a physician achieved a Quality performance score of 31 in the 2017 performance year and a Quality score of 37 in the 2018 performance year, the following equation would be utilized to calculate the improvement score:

The improvement score cannot be negative, meaning that a practice that did not have an increase in performance would receive zero improvement points.

Once the improvement score is calculated, the Quality performance category score is determined using the following equation:

([total measure achievement points + measure bonus points]/total available measure achievement points) + improvement score, not to exceed 100 percent. 

The available measure achievement points will be 40 or 60 depending on whether you report the 4 measures in the radiation oncology measure set or 6 independent quality measures. The weight of the category, 50 percent, is then applied at the end of the calculation.

Using the same example as before, the Quality performance category score would be:

([37+0]/60)*100 = 61.6

61.6 + 1.9 = 63.5

In total, there are 112 activities from which to choose in 2018. 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.

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 contract with Clarity PSO so start the contracting process now. Join the more than 400 RO-ILS facilities.

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 Practice 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 16 improvement activities. One of the 16 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.

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.

Base

Activities are either medium-weighted (worth 10 points) or high-weighted (worth 20 points) — most activities are listed as medium-weighted. You can report any combination of medium and high-weighted activities to meet the necessary points for full credit.

As an individual or group from a large practice, you need a total of 40 points to receive full credit in the IA category. The following equation can be utilized to calculate IA category points awarded towards the CPS:

In the event you have received the “rural” or “Health Professional Shortage Area (HPSA)” designation from CMS, you will only need 20 points to receive full credit in the IA category. In this case, the following equation can be utilized to calculate IA category points awarded towards the CPS:

Practices certified as patient-centered medical homes (PCMH) automatically receive full credit and do not need to report additional activities.

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 groups practicing in free-standing centers, you can also apply for an exemption because of hardships, including:

• Insufficient internet connectivity
• Extreme and uncontrollable circumstances
• Lack of control over the availability of CEHRT

To receive the hardship exemption, practices need to submit an application explaining why the EHR technology is not available. 

If exempt, this category weight is reduced to 0 percent and redistributed to the Quality performance category.

For 2018 PI, eligible practices must use either 2014 or 2015 Edition Certified Electronic Health Records Technology to complete PI reporting. The complete list of certified systems and modules can be found on the ONC website.

CMS finalizes the following base measures. Failure to report on any of the following base measures results in 0 points for the PI category.

Overview

PI Score = Base Score + Performance Score + Bonus Score

PI Points towards CPS = PI Score (capped at 100 points) x 25%

The details of the base score, performance score, and bonus score are described below. The PI score cannot exceed 100 points.

Base Score

Reporting the four or five base measures is required to receive an PI base score. MIPS eligible practices must report either a “one” in the numerator for numerator/denominator measures, or a “yes” response for yes/no measures for each measure within the objectives, to earn all 50 points in the base score. The base score is all-or-nothing. 

Failure to report on any of the required measures results in 0 points in the base score and zero for the entire PI performance category. 

Performance Score

The performance score is based on measures that are applied above the base score requirements. With a few exceptions, for each additional reported measure, a practice will receive 1 to 10 points. Since there are less overall measures for utilization of 2014 Certification EHR, two of the measures (Provide Patient Access and Health Information Exchange) are worth up to 20 points. Additionally, there are specific performance measures, like reporting to a public health agency or clinical data registry, that can earn up to 10 performance points. Overall, there is a total possible performance score of 90 points. See the QPP website for the full list of performance measures.

Bonus Points

Bonus points are also available. A 5-point bonus will be awarded for reporting to one or more additional public health and clinical data registry. A 10-point bonus will be awarded to reporting Improvement Activities using CEHRT. There is also a 10-point bonus for using 2015 Edition software exclusively in 2018.

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 

• Clinicians who do not see patients in the hospital will not be attributed to any episodes and not scored on the measure
• Clinicians must be attributed to at least 35 cases to be scored on the measure

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.

• The beneficiary is attributed to the primary care physician (PCP) who provided the most primary care services during the performance period.
• If a PCP did not bill any primary care services for a beneficiary, then the beneficiary is attributed to the specialist who provided the most primary care services during the performance period
• Clinicians must be attributed to at least 20 unique beneficiaries to be scored on this measure.

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.

CMS has stated, for the 2018 performance period, a clinician or group's average HCC score, dual ratio eligibility and resulting complex patient bonus score will be communicated as part of the final feedback shared in July 2019. If technically feasible, CMS will make this information available earlier through an existing communication channel. Please check prior Quality and Resource Use Report (QRUR) to determine if these measures were calculated for you under the old Value Based Modifier (VBM) program.

Base

Cost will be measured using administrative claims data, if the case minimum of attributed patients is met for a measure and a benchmark has been established. Benchmarks are based on data from the current performance year and utilized to compare the performance of MIPS eligible clinicians and groups. The Cost score is the average of the two measures. If only one measure can be scored, the score of that one measure will be the entire Cost performance category score. In the case where neither measure can be scored, which is likely for many radiation oncologists, the 10 points from the Cost category will be re-weighted to the Quality performance category.

Improvement

Unlike the Quality performance category, the improvement score in Cost is based on each specific measure performance. CMS will award up to one point for significant change in performance, only when there’s sufficient data to measure improvement.