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 |
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) |
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 |
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 | |
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 | |
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 | |
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 | |
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 | |
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 | |
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 | |
Procedural | Pre-Trigger Period = 30 days Post-Trigger Period = 90 days | Beneficiaries who undergo a CABG procedure during the performance period. | Acute inpatient hospitals | |
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: |
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 | |
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 |
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 |