Beware: The MIPS Shell Game

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Original story posted on: March 27, 2019

Weighting changes will be implemented for the 2019 calendar year.

Important changes for the 2019 calendar year in healthcare include Merit-Based Incentive Payment System (MIPS) category weighting changes.

The quality category will decrease in importance, with a shift of 5 percent, going from 50 to 45 percent of the overall score contribution. The cost category will increase in importance, going from 10 to 15 percent of the overall score contribution, progressing towards the ultimate target of 30 percent. The performance improvement category remains unchanged at 25 percent of the overall score contribution, as does interoperability at 15 percent. In addition, the minimum score to prevent a negative payment adjustment is 30, which is double the score of 15 required in 2018 (average score in 2017 was 55.08).

A change included in Section 51003(a)(2) of the Bipartisan Budget Act of 2018 amended Section 1848(r)(2) of the Social Security Act and requires various information in regards to MIPS be provided on the website of the Centers for Medicare & Medicaid Services (CMS) no later than Dec. 31 each year (beginning with 2018, when it was published on or about Dec. 22).

An additional important change in 2019 was mandated in previous regulation. The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) of 2015 required CMS to develop measures for potential implementation in the cost performance category of MIPS. CMS contracted with Acumen, LLC to develop a methodology for analyzing cost, as appropriate, through consideration of patient condition groups and care episode groups.

Episode-based cost measures represent the cost to Medicare for the items and services furnished during an episode of care and inform clinicians on the cost of care for which they are responsible during an episode’s timeframe. They only include items and services that are related to the episode for a clinical condition or procedure (coding-derived), as opposed to including all services provided to a patient over a given timeframe.

As a result, CMS and Acumen developed eight episode-based (risk-adjusted) cost measures, which clinicians are responsible for during a specified timeframe and were implemented for the 2019 MIPS performance period.

So the cost performance category of MIPS for the 2019 performance period will include 10 measures:

(a) MSPB; (b) TPCC; and (c) eight episode-based cost measures.

The eight episode-based cost measures address 3.70 percent of total Medicare Parts A and B spending. They are divided into procedural and acute inpatient categories. In addition, the procedural category can be subdivided into three baskets by differing pre-procedure and post-procedure cost inclusion.

Procedural

  • Pre-Trigger Period of 30 days and Post-Trigger Period of 90 days      
  • Knee Arthroplasty (1.22 percent of Total Medicare Parts A and B Spending)
  • Revascularization for Lower Extremity Chronic Critical Limb Ischemia
  • Post-Trigger Period of 30 days                 
  • Elective Outpatient Percutaneous Coronary Intervention (PCI)
  • Routine Cataract Removal with Intraocular Lens (IOL) Implantation
  • Post-Trigger Period of 14 days
  • Screening/Surveillance Colonoscopy

Acute Inpatient Medical Condition (All with Post-Trigger Period of 30 days)

  • Simple Pneumonia with Hospitalization
  • ST-Elevation Myocardial Infarction (STEMI) with PCI
  • Intracranial Hemorrhage or Cerebral Infarction (0.71 percent of Total Medicare Parts A and B Spending)
  • CMS is also looking into the following areas for inclusion in 2020:

Procedural

  • Acute Kidney Injury Requiring New Inpatient Dialysis
  • Elective Primary Hip Arthroplasty
  • Femoral or Inguinal Hernia Repair
  • Hemodialysis Access Creation
  • Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
  • Lumpectomy, Partial Mastectomy, Simple Mastectomy
  • Non-Emergent Coronary Artery Bypass Graft (CABG)

Acute Inpatient Medical Condition

Larry Field DO, MBA, CHCQM, CPC, CHC, LHRM, ICD10 CM/PCS Trained, Baldrige Trained

Dr. Larry Field is an internist in Ocala, Fla. He received his medical degree from Nova Southeastern University College of Osteopathic Medicine. Dr. Field is treasurer of the American College of Physician Advisors (ACPE). 

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