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2021 MIPS Cost Performance Category

The cost performance category is an important part of MIPS. Although clinicians don’t personally determine the price of individual services provided to Medicare patients, they can affect the amount and types of services provided. By better coordinating care and seeking to improve health outcomes by ensuring their patients receive the right services, clinicians play a meaningful role in delivering high-quality care at a reasonable cost.

Cost Measures

There are 20 total cost measures for the 2021 performance period. CMS uses Medicare claims data to calculate cost measure performance which means clinicians do not have to submit any data for this performance category

Measure Name

Description

Case Minimum

Data Source

Total Per Capita Cost (TPCC)

Assesses the overall cost of care delivered to a Medicare patient with a focus on primary care received.

20 Medicare patients

 

•Medicare Parts A and B claims data

 

Medicare Spending Per Beneficiary Clinician (MSPB Clinician)

Assesses the cost of care for services related to qualifying inpatient hospital stay (immediately prior to, during, and after) for a Medicare patient

35 episodes

 

•Medicare Parts A and B claims data

 

13 Procedural episode-based measures and 5 acute inpatient medical condition episode-based measures (18 measures)

Assess the cost of care that is clinically related to initial treatment of a patient and provided during an episode’s timeframe.

20 episodes for acute inpatient condition episode-based measures, 10 episodes for procedural episode-based  measures

 

•Medicare Parts A and B claims data

 

Procedural episode-based measures

Measure Name

Measure Type

Episode Window

This Measure Evaluates a Clinician’s Risk Adjusted Cost to Medicare for…

Measures Can Be Triggered Based on Claims Data from the Following Settings:

Elective Outpatient Percutaneous Coronary Intervention (PCI)

Procedural

Pre-Trigger Period = 0 days

Post-Trigger Period = 30 days

Patients who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period.

Ambulatory/office-based care centers, hospital outpatient departments (HOPDs),

Ambulatory surgical centers (ASCs)

Knee Arthroplasty

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Patients who receive an elective knee arthroplasty during the performance period.

Acute inpatient (IP) hospitals, HOPDs, ambulatory/office-based care centers, and ASCs

Revascularization for Lower Extremity Chronic Critical Limb Ischemia

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Patients who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia during the performance period.

ASCs, HOPDs and acute IP hospitals

Routine Cataract Removal with Intraocular Lens (IOL) Implantation

Procedural

Pre-Trigger Period = 60 days

Post-Trigger Period = 90 days

Patients who undergo a procedure for routine cataract removal with intraocular lens implantation during the performance period.

ASCs, ambulatory/office-based care, and HOPDs

Screening/Surveillance Colonoscopy

Procedural

Pre-Trigger Period = 0 days

Post-Trigger Period = 14 days

Patients who undergo a screening or surveillance colonoscopy procedure during the performance period.

ASCs, ambulatory/office-based care, HOPDs

Acute Kidney Injury Requiring New Inpatient Dialysis

Procedural

Pre-Trigger Period = 0 days

Post-Trigger Period = 30 days

Patients who receive their first inpatient dialysis service for acute kidney injury during the performance period.

Acute IP hospitals

Elective Primary Hip Arthroplasty

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Patients who receive an elective primary hip arthroplasty during the performance period.

Acute IP hospitals, HOPDs, ambulatory/office-based care centers, and ASCs

Femoral or Inguinal Hernia Repair

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Patients who undergo a surgical procedure to repair a femoral or inguinal hernia during the performance period.

Acute IP hospitals, HOPDs, ambulatory/office-based care centers, and ASCs

Hemodialysis Access Creation

Procedural

Pre-Trigger Period = 60 days

Post-Trigger Period = 90 days

Patients who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period.

Ambulatory/office-based care centers, OP hospitals, and ASCs

Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Patients who undergo surgery for lumbar spine fusion during the performance period.

ASCs, HOPDs, and acute IP hospitals

Lumpectomy Partial Mastectomy, Simple Mastectomy

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Patients who undergo partial or total mastectomy for breast cancer during the performance period.

Ambulatory/office-based care centers, outpatient hospitals, and ASCs

Non-Emergent Coronary Artery Bypass Graft (CABG)

Procedural

Pre-Trigger Period = 30 days

Post-Trigger Period = 90 days

Beneficiaries who undergo a CABG procedure during the performance period.

Acute inpatient hospitals

Renal or Ureteral Stone Surgical Treatment

Procedural

Pre-Trigger Period = 90 days

Post-Trigger Period = 30 days

Patients who receive surgical treatment for renal or ureteral stones during the performance period.

Acute inpatient hospitals, HOPDs, ambulatory/office-based care centers, and ASCs

Acute inpatient medical condition episode-based measures

Measure Name

Measure Type

Episode Window

This Measure Evaluates a Clinician’s Risk Adjusted Cost to Medicare for…

Measures Can Be Triggered Based on Claims Data from the Following Settings:

Intracranial Hemorrhage or Cerebral Infarction

Acute inpatient medical condition

Pre-Trigger Period = 0 days

Post-Trigger Period = 90 days

Patients who receive inpatient treatment for cerebral infarction or intracranial hemorrhage during the performance period.

Acute inpatient hospitals

Simple Pneumonia with Hospitalization

Acute inpatient medical condition

Pre-Trigger Period = 0 days

Post-Trigger Period = 30 days

Patients who receive inpatient treatment for simple pneumonia during the performance period.

Acute inpatient hospitals

ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)

Acute inpatient medical condition

Pre-Trigger Period = 0 days

Post-Trigger Period = 30 days

Patients who present with ST-Elevation Myocardial Infarction indicating complete blockage of a coronary artery who emergently receive Percutaneous Coronary Intervention as treatment during the performance period.

Acute inpatient hospitals

Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

Acute inpatient medical condition

Pre-Trigger Period = 0 days

Post-Trigger Period = 60 days

Patients who receive inpatient treatment for an acute exacerbation of COPD during the performance period.

Acute inpatient hospitals

Lower Gastrointestinal Hemorrhage (applies to groups only)

Acute inpatient medical condition

Pre-Trigger Period = 0 days

Post-Tigger period = 35 days

Patients who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract during the performance period.

Acute inpatient hospitals

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