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.
- If a clinician or group does not meet the minimum number of cases for any of the cost measures, the cost category will be reweighted.
- The most common applicable cost measures are Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary (MSPB).
- Attribution: To calculate cost scores, the costs of each patient's treatment must be attributed to a specific clinician or group. Each measure has its own method for attributing costs to clinicians.
- Risk adjustment accounts for factors such as clinical risk factors( for example - age, diabetes, heart failure, etc) that may affect the cost of care provided. All measures in the cost performance category are adjusted to account for clinical risk. This allows for a more accurate comparison of the costs of care provided by different clinicians or groups. In addition, the TPCC measure is also specialty-adjusted.
- CMS-HCC risk scores: Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Categories (HCC) risk scores measure a person’s expected health expenditures relative to the average of 1.0. A beneficiary with a risk score of 2.0 is expected to incur twice the medical expenditures of the average Medicare fee-for-service beneficiary, and a beneficiary with a risk score of 0.5 is expected to incur half the medical expenditures of the average. CMS-HCC risk scores are computed annually and based on beneficiaries’ demographic and diagnosis information. CMS-HCC risk scores are calculated using all applicable Medicare claims submitted for the individual beneficiary. Your practice’s billing for the beneficiary contributes to the overall risk score, as does all other entities’ billing. The accuracy of a beneficiary’s CMS-HCC risk score depends on accurate billing of all Medicare claims for the beneficiary that contribute with applicable diagnosis information during the risk score year. HCCs are assigned using hospital and physician applicable diagnoses from the following sources: (1) hospital inpatient – principal diagnoses, (2) hospital inpatient – secondary diagnoses, (3) hospital outpatient, and (4) physician and clinically trained non-physician (e.g., psychologist, nurse practitioner). These sources of diagnoses have been found to be the most reliable and most strongly associated with health expenditures.
- Payment standardization is the process of adjusting the allowed charge for a Medicare service to facilitate comparisons of resource use across different geographic areas. This process assigns a comparable allowed amount for the same service provided by different providers and/or in different settings, allowing for differences in spending to be attributed solely to care decisions and resource use. This is used in the calculation of MIPS cost measures to ensure that comparisons of costs are fair and accurate.
- Benchmarks - CMS calculates a single, national benchmark for each cost measure. These benchmarks are based on the performance year, not a historical baseline period. All MIPS eligible clinicians that meet or exceed the minimum number of cases for a measure are included in the same benchmark. CMS will publish these benchmarks in summer 2023 once final performance feedback is available. Please note that because of Covid public health emergency, the cost performance category was reweighted to 0% for the 2020 and 2021 performance years, so no benchmark data was published for those years.
- To help clinicians understand the cost measures, CMS provided patient-level reports on the 2021 cost measures for which clinicians, groups, and virtual groups met the minimum number of cases. This information may be useful in anticipating when episodes will be triggered and attributed to them. These patient-level reports are available as part of the final performance feedback that be found in the practice account with QPP. Clinicians can also review the 2021 MIPS Performance Feedback Patient-Level Data Reports Supplement.
Cost Measures
There are 25 total cost measures for the 2023 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 |
| This population-based measure 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
| |
| This population-based measure 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
| |
15 procedural episode-based | Assess the cost of care that’s clinically related to a specific procedure provided during an episode’s timeframe. | 10 episodes for all procedural episode-based measures except the Colon and Rectal Resection measure which has a case minimum of 20 episodes. |
•Medicare Parts A and B claims data
|
| 6 acute inpatient medical condition episode-based measures | Assess the cost of care clinically related to specific acute inpatient medical conditions and provided during an episode’s timeframe. | 20 episodes for acute inpatient condition episode based measures | •Medicare Parts A and B claims data |
| 2 chronic condition episode based measures | Assess the cost of care clinically related to the care and management of patients’ specific chronic conditions provided during a total attribution window divided into episodes. | 20 episodes for chronic condition episode-based measures | •Medicare Parts A, B and D 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, outpatient hospitals, Ambulatory surgical centers (ASCs) |
Procedural | Pre-Trigger Period = 30 days Post-Trigger Period = 90 days | Patients who receive an elective knee arthroplasty during the | Acute inpatient (IP) hospitals, hospital outpatient department (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 | PPatients who receive an 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 | Patients who undergo a CABG procedure during the performance period. | Acute IP 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 IP hospitals, HOPDs, ambulatory/office-based care centers, and ASCs | |
| Melanoma Resection | Procedural | Pre-Trigger Window: 30 days Post-Trigger Window: 90 days | Patients who undergo an excision procedure to remove a cutaneous melanoma during the performance period. | ASCs, ambulatory/office-based care, and HOPDs. |
| Colon and Rectal Resection | Procedural | Pre-Trigger Window: 15 days Post-Trigger Window: 90 days | Patients who receive colon or rectal resection for either benign or malignant indications during the performance period. | ASCs, HOPDs, and acute IP hospitals. |
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 IP 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 IP 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 STEMI indicating complete blockage of a coronary artery who emergently receive PCI as treatment during the performance period. | Acute IP 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 IP 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 IP hospitals | |
| Sepsis | Acute inpatient medical condition | Pre-Trigger Window: 0 days Post-Trigger Window: 45 days | Patients who receive inpatient medical treatment for sepsis during the performance period. | Acute IP hospitals. |
Chronic 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: |
| Chronic condition | An episode is a segment of time during which clinicians | Patients receiving medical care to manage and treat diabetes. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Diabetes episode. | The measure focuses on care provided by clinicians practicing in non-IP hospital settings for patients with diabetes. The most frequent settings in which a Diabetes episode is triggered include: Office, Skilled Nursing Facility (SNF), and OP Hospital. | |
| Chronic condition | An episode is a segment of time during which clinicians or clinician groups are assessed for the care that they provide to a patient with asthma or COPD. The episode window length for the Asthma/COPD measure is between 1 year (365 days) and 2 years minus 1 day (729 days) and can vary in length across patients. | Patients receiving medical care to manage and treat asthma or COPD. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during an Asthma/COPD episode. | The measure focuses on care provided by clinicians practicing in non-IP hospital settings for patients with asthma or COPD. The most frequent settings in which an Asthma/COPD episode is triggered include: Office, SNF, and OP Hospital. |