2020 is the fourth year for the Quality Payment Program (QPP). Many radiation oncologists will continue to participate in the Merit-based Incentive Payment System (MIPS) even with the pending radiation oncology-specific Advanced Alternative Payment Model (RO-Model). 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:
The rules and requirements have changed each year of the MIPS program. Here is a list of the major modifications from previous years. More information about these topics can be founded in the referenced section:
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). These 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 45 points to avoid the 9 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 85 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 2020, practices must submit data from more than one performance category to achieve 45 points.
There are three reporting options for MIPS based on TIN/NPI combination. The decision to report as an individual, group or virtual group is part of your MIPS strategy and will be unique to your practice.
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. 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.
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.
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 III (QRDA3) 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 HCQIS Access Roles and Profile (HARP) system credentials and have the appropriate user role associated with your organization. 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.
2020 repeats the 2019 bonus opportunities:
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 22.2 percent.
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.
An eligible clinician or group’s overall payment adjustment is based on the Composite Performance Score (CPS). For 2020, the CPS score is based on four performance categories: Quality, Promoting Interoperability, Improvement Activities and Cost. There are specific circumstances where a practice may not qualify for a certain performance category. For those cases, CMS has created reweighting scenarios, shown in this table.
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.
In most cases each measure will receive a total score from 0 to 10 points based on reporting and performance. However, CMS has created scoring policies for measures that cannot be scored because they do not meet case minimums, do not have benchmarks or do not meet data completeness requirements.
As a reminder, physicians must submit data on 70% 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 70 percent of all Medicare Part B patients that meet the measure’s denominator during the reporting period.
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 = (2020 Quality Score - 2019 Quality Score) x10
2019 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. In 2020, CMS has lowered the Group threshold from 100 percent hospital-based to 75 percent to match the definition used for the individual clinician.
Starting in 2020, the PI category is automatically reweighted for Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists.
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.
For 2020, 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 2020, including two new activities, seven modified activities and the removal of 15 activities. 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.
In 2020 groups can attest to an improvement activity when at least 50% of the clinicians perform the same activity during any continuous 90-day period within the same performance year.
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 email@example.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).
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 cost measure, now called MSPB Clinician (MSPB). The re-evaluated MSPB-C measure assessed teh cost performance of clinicians who furnish inpatient care services to Medicare beneficiaries. the measure includes Medicare Part A and B costs occurring during the episode window, removing certain services identified as unlikely to be influenced by the clinician's care decisions. Medical episodes are attributed to clinician groups that render at least 30 percent of E&M services during the period between the index admission date and the discharge date for a hospitalization with a medical MS-DRG, and to any clinician that billed at least one E&M service under a clinician group that meets the 30 percent threshold.
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 2020.
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 attribution methodology for this measure has been re-evaluated for the 2020 performance year. The new methodology removes clinicians who frequently perform non-primary care services, including radiation therapy, chemotherapy and surgery. However, other clinicians, such as Nurse Practitioners can still be attributed beneficiaries.
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 15 points from the Cost category will be re-weighted.
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.