Merit based Incentive Payment System (MIPS) - What is MIPS?

 

What is MIPS?

The Merit based Incentive Payment System (MIPS), established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), came into effect on January 1, 2017. It is a major catalyst towards transforming the healthcare industry from fee-for-service to pay-for-value.

MIPS rolled 3 existing quality and value reporting programs (PQRS, VBM and MU) into one points based program.

MIPS annually scores eligible Medicare Part B clinicians on a 100-point performance scale which results in a Composite Performance Score (CPS). The payment adjustment will be based on this Composite Performance Score which is calculated by the measures and categories reported. MIPS is designed to be a budget-neutral program, but there is $500 million allocated to provide additional incentive to exceptional performers- those earning 85 or more points in 2021.

The Quality Payment Program (QPP) consists of two major tracks:

  • The Merit-based Incentive Payment System (MIPS)
  • Alternative Payment Models (APMs)

Most providers will initially participate through MIPS.

The 4 scorable MIPS categories in 2021 are:

  • Quality (40% of score)
  • Promoting Interoperability (25% of score)
  • Improvement Activities (15% of score)
  • Cost (20% of score)

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What are the differences between MIPS 2020 and MIPS 2021?

RulesMIPS 2020MIPS 2021
Low Volume Threshold to be Eligible
  • $90,000 in Medicare Part B allowed charges for covered professional services only AND provide care to 200 Medicare Part B beneficiaries AND Delivering more than 200 covered services to Part B beneficiaries.  Opt-in available if you exceed at least 1 of these thresholds.

     

     


     

No change

Determination Periods

Two Determination Periods for the Low-Volume Threshold (LVT):

  • First 12-month segment: Oct. 1, 2018 to Sept. 30, 2019 (including a 30-day claims run out)
  • Second 12-month segment: Oct. 1, 2019 to Sept. 30, 2020 (including a 30-day claims run out)

 

 

The MIPS determination period includes two 12-month segments:

  • First 12-month segment: Oct. 1, 2019 to Sept. 30, 2020 
  • Second 12-month segment: Oct. 1, 2020 to Sept. 30, 2021 
Payment Adjustment Range-9% to +9x%No Change
Minimum MIPS score to avoid penalty45 points60 points
Exceptional Performance Threshold85 pointsNo Change
Cost Category Weight15%20%
Bonus Points
  • Small Practice Bonus (+6) - applied only to Quality category (if reported).
  • Bonus points (up to 10% of score) added to Quality for additional Outcome or HP, ETE reporting.
  • Complex patient bonus (if applicable) calculated by CMS upon submission and applied to final score.
  • Improvement score calculated by CMS upon submission.

                        No change

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Who has to report MIPS in 2021?

  • 2021 MIPS eligible clinicians who bill for Medicare Part B (otherwise known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH and meet the low volume threshold (LVT) include:
    • Physicians (MD/DO, DDS, DDM, DPM, Optometrists, and Chiropractors)
    • Physician assistants
    • Nurse practitioners
    • Clinical nurse specialists
    • Certified registered nurse anesthetists
    • Physical or occupational therapists
    • Speech-language pathologists
    • Audiologists
    • Nurse midwives
    • Clinical psychologists
    • Dieticians/nutritional professionals
  • Could I be exempt from MIPS?
    • Yes! The following providers are exempt from MIPS:
      • Newly enrolled in Medicare (exempt until the following performance year)
      • Clinicians meeting a low-volume threshold ($90,000 or less in billed Medicare Part B allowed charges or provide care for 200 or fewer Medicare Part-B enrolled patients in one year)
      • Clinicians significantly participating in "alternative payment models" (APMs)
      • Note: MIPS non-eligible clinicians would be permitted to voluntarily report under MIPS in 2021, but will not be subject to the MIPS payment adjustment.
      • To check if you need to submit 2021 MIPS data, please visit the CMS MIPS Participation Status website.
  • What is the MIPS Extreme and Uncontrollable Circumstance Policy for 2021?
    • Clinicians impacted by natural disasters or Covid can claim the hardship exception for all the performance categories - Quality, Cost, Improvement Activities, and Promoting Interoperability.
    • The deadline for the hardship exception application is December 31, 2021.
    • CMS Exception Applications

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Can providers participate in MIPS as an individual provider or a group practice?

  • Providers can choose to participate in MIPS as either:
    • An Individual (defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN); OR
    • A group is defined as at least 2 clinicians (identified by their individual NPIs) sharing a common TIN. At least 1 clinician must be individually eligible for MIPS.
  • Important: The decision to report individually or as a group, applies across all MIPS categories for a given performance year. A clinician cannot choose to report as an individual in some categories while reporting as a group for other categories. The decision to report as a group or by individual clinicians has financial and reputational ramifications that should be taken into consideration.
  • Individual Reporting:
    • The data is reported for every eligible clinician in the group for all four MIPS performance categories (or for just the categories the clinician chooses to submit).
    • The MIPS score will be calculated based on individual performance reported, and the payment adjustment will be calculated accordingly.
    • Clinicians billing CMS with two (or more) different TINs would possibly need to report each combination and would, in this scenario, receive MIPS scores and separate payment adjustments for each TIN/NPI combination.  The QPP participation tool will provide information on the clnician's practices.
  • Group Reporting:
    • A group will be measured as a group practice across all 4 MIPS performance categories (or just the categories they choose to report/attest to). Data is aggregated at the group-level for each of the MIPS categories and then reported.
    • All the eligible clinicians in the group will get one MIPS score based on the group’s performance.
    • There is no CMS enrollment process or deadline for reporting as a group.
    • An organization must include the data from all the clinicians in the group, including clinicians who are otherwise excluded from MIPS individually due to low volume, newly Medicare enrolled status or QP status from an Advanced APM.
    • Individual Promoting Interoperability data can be excluded from group reporting for some clinician types such as non-patient facing or hospital-based clinicians. Their data must be included in the other categories for group reporting but the group can choose to remove them from the TIN level data for PI.
  • Virtual Group Reporting:
    • Virtual Groups are composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together “virtually” with at least 1 other such solo practitioner or group to participate in MIPS for a performance period of a year.
    • A solo practitioner or group can only participate in 1 virtual group in any performance period. But, there are no limits on how many solo practitioners and groups can join a virtual group.
    • If a group chooses to join a virtual group, all of the eligible clinicians in that group have to be included in the virtual group. Any group that wants to be part of a virtual group must have 10 or fewer eligible clinicians.
    • The majority of MIPS group scoring rules apply to virtual groups.
    • Clinicians in a Virtual Group will report as a Virtual Group across all 4 performance categories (or the just the categories they choose to report) and will need to meet the same measure and performance category requirements as non-virtual MIPS groups.
    • Solo practitioners and groups who want to form a virtual group must go through an election process. Virtual groups election must occur prior to the beginning of the performance period and cannot be changed once the performance period starts. Election period was October 11 to December 31, 2020, for the 2021 MIPS performance period.
    • In order to participate in MIPS as a virtual group for the 2021 performance period, virtual groups are required to have submitted an election to CMS via e-mail (MIPS_VirtualGroups@cms.hhs.gov) by December 31, 2020.

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What are the 2021 MIPS Categories?

Providers participating in the MIPS program will receive a “composite performance score” based on their performance in 4 categories:  

Quality
Quality
 

40% of total score

Advancing Care Information
Promoting Interoperability (PI)
 

25% of total score 
Improvement Activities
Improvement Activities
15% of total score 

Cost
Cost
(based on admin. claims data)

20% of total score 

More details about MIPS Categories...

Quality Details - 40% of score*

  • Report 6 measures with one Outcome, or if no Outcome applicable, another High Priority measure (Appropriate Use, Patient Safety, Efficiency, Patient Experience, or Care Coordination).
  • Data Completeness: Each measure is reported on at least 70% of eligible cases over the entire year (all insurances) per the denominator criteria published for each measure**.
  • Measures must have at least 20 records in the denominator (and contain at least 70% of eligible cases) to be scored against national benchmarks (e.g. receive a score higher than 3 points).
  • A clinician may choose to report a specialty measure set, defined by CMS for a particular specialty. If a specialty measure set contains fewer than 6 measures, then a clinician could still achieve the maximum possible score for the Quality category by reporting all the measures in the measure set. Specialty measure sets are identified in the Suggestions by Specialty page which can be found here.
  • If a clinician cannot identify 6 applicable measures, they may still be able to achieve the maximum score in the Quality category by passing a validation process called Eligible Measure-Applicability (EMA)
  • Multiple submission methods can be chosen to submit quality measures.

*This weight will be 65% if provider/group is exempt from PI or 60% if Cost cannot be calculated.

**View the list of the 2021 Quality measures with documentation here.

Promoting Interoperability Details  - 25% of score

  • What is PI? This performance category promotes patient engagement and electronic exchange of information using certified electronic health record technology (CEHRT).
  • There are ten (10) measures spread across four (4) objectives:

    • Objective: e-prescribing
    • Objective:  Provider to Patient Exchange
    • Objective: Health Information Exchange - Option 1 or Option 2
    • Objective:  Public Health and Clinical Data Exchange (report 2 measures for 10 points)
      • Immunization Registry Reporting**
      • Syndromic Surveillance Reporting**
      • Electronic Case Reporting**
      • Public Health Registry Reporting**
      • Clinical Data Registry Reporting**
      • **There are exclusions available for most of the PI measures. If you meet and claim the exclusion for one or more of the required Promoting Interoperability performance category measures, the points for the measure will be redistributed to another measure or measures.
      •  In addition to submitting measures, clinicians must:
        • Submit a “yes” to the Prevention of Information Blocking Attestation,
        • Submit a “yes” to the ONC Direct Review Attestation; and
        • Submit a “yes” for the security risk analysis measure. The analysis or review must be conducted on an annual basis and within the calendar year of the performance period.
      • How is PI Category reweighted?:
        • Automatic Reweighting:  PI will automatically be reweighted to 0% (and weight will be added to the quality category - making it 65% of total score) without submitting an application for:
          • Hospital-based MIPS eligible clinicians - >75% of the MIPS eligible clinicians in the group being hospital-based
          • Non-Patient-Facing clinicians or groups with >75% NPF clinicians
          • Ambulatory Surgical Center (ASC) based MIPS eligible clinicians 
          • MIPS eligible Physician Assistants, Nurse Practitioners, Clinical Nurse Specialist, and Certified Registered Nurse Anesthetists, new:  Physical Therapists, Occupational Therapists, Qualified speech-language pathologists, Qualified audiologists, Clinical Psychologists, Registered dietitian or nutrition professionals
          • If you qualify for automatic reweighting you can still choose to report if you’d like. In this scenario, PI will become 25% of your score and Quality will not be reweighted.
          • If reporting as a group, all MIPS eligible clinicians in the group must qualify for reweighting with the exception of non-patient facing category.  To be designated as a non-patient facing group, 75% of the clinicians in the group must be non-patient facing.
      • Reweighting by Hardship Exception Application: Eligible clinicians can submit an application by December 31, 2021 to claim the hardship exception and get the PI category reweighted to 0% (and weight added to the Quality category). Clinician will qualify to file for an exception in following situations:
        • Clinicians in a Small Practice (1-15 eligible clinicians) facing overwhelming barriers to adopting a certified EHR 
        • Clinicians whose EHR was decertified during the performance year
        • MIPS Eligible Clinicians facing significant hardship defined as:
          • Have insufficient internet connectivity
          • Extreme and uncontrollable circumstances (e.g. Natural Disasters, practice closure, financial distress, vendor issues)
          • Lack of control over the availability of CEHRT
        • Note:  Not having CEHRT is not sufficient by itself to qualify for reweighting. 
      • CMS Exception Applications

    Improvement Activities (IA) Details: - 15% of Score

    • What is IA? IA rewards clinicians for delivering care that emphasizes care coordination, beneficiary engagement and patient safety.
    • Performance in this category is calculated based on the provider’s attestation to completing 2 high-weighted activities or 4 medium-weighted activities* for a minimum of 90 continuous days.
    • *Special scoring consideration is given to:
      • small practices (less than 15 in the TIN),
      • rural practices,
      • health professional shortage areas (HPSAs),
      • or non-patient facing clinicians.
    • These categories of providers are only required to report 1 high-weighted or 2 medium-weighted activities for full participation.
    • Groups must have at least 50% of the clinicians completing the activity.
    • If 50% of the practice sites within a TIN are certified as Patient Centered Medical Home (PCMH), the TIN will earn full credit for the IA category.
    • In 2021, there are approximately 107 published activities.
    • View the list of Improvement Activities and the Data Validation criteria here .

    Cost - 20% of Score

    • The Cost performance category reporting period is calculated based on the full year in 2021.
    • A total of 20 cost measures are used to evaluate performance in the Cost performance category in the 2021 MIPS Performance Period. 
    • No submissions will be required for the Cost category. Cost category score will be calculated from Medicare administrative claims.
    • Similar to the calculation of Quality performance category score, the Cost score will be calculated by comparing performance against benchmarks and the points will be assigned on a decile system. However, the benchmarks for Cost measures will be based on the same year’s performance unlike the Quality benchmarks which are based on historical performance.
    • Each measure will be scored only if the reporting entity meets the case minimum requirement for the measure. For 2020, the minimum number of cases required for each measure are:
      • Medicare Spending Per Beneficiary Clinician (MSPB) – minimum of 35 cases
      • Total Per Capita Cost for all attributed beneficiaries - minimum of 20 cases
      • 18 episode-based measures - minimum 20 episodes for acute inpatient measures and 10 episodes for procedural measures
        • Elective Outpatient Percutaneous Coronary Intervention (PCI)
        • Knee Arthroplasty
        • Revascularization for Lower Extremity Chronic Critical Limb Ischemia
        • Routine Cataract Removal with Intraocular Lens (IOL) Implantation
        • Screening/Surveillance Colonoscopy
        • Intracranial Hemorrhage or Cerebral Infarction
        • Simple Pneumonia with Hospitalization
        • ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)
        • Acute Kidney Injury Requiring New Inpatient Dialysis
        • Elective Primary Hip Arthroplasty
        • Femoral or Inguinal Hernia Repair
        • Hemodialysis Access Creation
        • Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
        • Lower Gastrointestinal Hemorrhage (*only for groups) 
        • Lumbar Spine Fusion for Degenerative Disease, 1–3 Levels 
        • Lumpectomy Partial Mastectomy, Simple Mastectomy Non-Emergent
        • Coronary Artery Bypass Graft (CABG) 
        • Renal or Ureteral Stone Surgical Treatment
    • If only one measure can be scored, the performance on that measure will determine the Cost category score.
    •  If none of the 20 measures can be scored, the MIPS eligible clinician/group will not be scored on cost and the performance categories would be reweighted as follows: Quality performance category will be reweighted to 60% of the 2021 MIPS Final Score, the Improvement Activities (IA) performance category will be 15% and the Promoting Interoperability (PI) performance category will be 25%. 
    •  In all performance years, the Cost performance category is assigned a weight of 0% for MIPS eligible clinicians scored under the APM scoring standard as MIPS APM participants being assessed on cost and utilization via the requirements for participation in the MIPS APM.

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    What determines my final MIPS Score (CPS)?

    MIPS COMPOSITE PERFORMANCE SCORE (CPS) - Max Score = 100 points

    Final MIPS Score = Quality Weighted Score (40%) + PI Weighted Score (25%) + IA Weighted Score (15%) + Cost Weighted Score (15%) + Complex Patient Bonus (if applicable) + Small Practice Bonus (if applicable)

    • The MIPS score earned by a clinician or group for the performance period determines the adjustment applied to every Medicare Part B payment to the clinician.
    • The payment adjustment occurs in the second calendar year after the performance year. So, for PY2021, the payment adjustment would occur beginning with 2023 reimbursements.

    Quality Scoring (40% of score or up to 40 points toward MIPS score):

    • Data Completeness Requirements: Minimum 70% data completeness is required to achieve the maximum points for each measure. You must report at least 70% of your total patients who meet the measure's denominator criteria, regardless of payer (Medicare and Non-Medicare).  Less than 70% completeness will not yield any points for large practices (Small Practices will still achieve 3 points).
    • Case Minimum of 20: For all Quality measures, you must report at least 20 cases, i.e., the denominator must be 20 or more for the measure to be compared against national benchmarks to earn more than 3 points (1 point for larger practices). For example, a Numerator/Denominator of 19/19 will achieve only 3 points (or 1 point for larger practices), but Numerator/Denominator of 19/20 could achieve 10 points.
    • No Benchmarks: Measures that are not benchmarked will (initially) receive 3 points regardless of performance. It is possible that when CMS does the final analysis of the reported data, benchmarks for these measures will have been published. The baseline period for deriving benchmarks is generally two years prior to the performance year.  
    • 2021 MIPS Quality Benchmarks 

    How Quality Score is Calculated:

    Note: You cannot earn more than 100% of the maximum points for a performance category. If the maximum points for a clinician is 60 and they earn a total of 66 points including bonuses, their score will be capped at 60 points (and then weighted at 40%). In this scenario, you would get full credit for the Quality category (40 points) towards calculation of your final MIPS Score.

    1. Determine the maximum points you can achieve (for most providers it will be at least 60 points):
      • If you are reporting a Specialty Measure Set that has less than 6 measures, the denominator for the Quality category will be re-adjusted (# of measures x 10) and your score calculated accordingly.
      • If the All-Cause Hospital Readmission Measure is applicable to your group (16 or more providers), your max points will increase by 10 points (to 70). CMS will calculate your performance in this measure from Administrative Claims data. It will be scored only if your group meets the minimum case requirement of 200 for this measure, and will be added to your Quality score by CMS to determine the final MIPS score.
      • For all other providers, you score will be based on 60 (6 measures x 10).
      • Sample calculation #1: Based on 60 points max in the denominator: 48 (number of achievement points earned over 6 measures reported)/60 x 40% x 100 = 32 points for Quality category
      • Sample calculation #2: Based on 40 points max in the denominator (if you report a specialty measures set with 4 measures: 32 (number of achievement points earned over 4 measures reported)/40 x 40% x 100 = 32 points earned for the quality category.
    2. Calculate Achievement Points:
      • Eligible clinicians can earn maximum of 10 points* for each of the measures reported.
      • The submission method, (Registry, EHR, etc.) and the corresponding benchmark will determine the points earned for each measure.
      • The maximum points for the following measures has been capped at 7 points (vs. 10 points). This holds true even if performance is 100%.
        • #8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
        • #14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination
        • #19 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
        • #21 Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin
        • #23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
        • #44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
        • #52 Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy
        • #65 Appropriate Treatment for Children with Upper Respiratory Infection (URI)
        • #76 Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
        • #93 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use
        • #102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
        • #104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
        • #117 Diabetes: Eye Exam
        • #130 Documentation of Current Medications in the Medical Record
        • #138 Melanoma: Coordination of Care
        • #143 Oncology: Medical and Radiation – Pain Intensity Quantified
        • #145 Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
        • #147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
        • #154 Falls: Risk Assessment
        • #178 Rheumatoid Arthritis (RA): Functional Status Assessment
        • #187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy
        • #195 Radiology: Stenosis Measurement in Carotid Imaging Reports
        • #249 Barrett's Esophagus
        • #250 Radical Prostatectomy Pathology Reporting
        • #254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
        • #264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer
        • #265 Biopsy Follow-Up
        • #279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
        • #283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
        • #286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
        • #291Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease
        • #293 Parkinson's Disease: Rehabilitative Therapy Options
        • #320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
        • #326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
        • #350 Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
        • #351 Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
        • #360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
        • #395 Lung Cancer Reporting (Biopsy/Cytology Specimens)
        • #396 Lung Cancer Reporting (Resection Specimens)
        • #397 Melanoma Reporting
        • #402 Tobacco Use and Help with Quitting Among Adolescents
        • #406 Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
        • #430 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
        • #436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
        • #440 Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician
        • #463 Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
    3. Add in CAHPS for MIPS Achievement Points (if applicable):
      • Groups and Virtual Groups can report CAHPs for MIPS survey as one quality measure towards the required 6 measures.
      • The survey comprises of 10 Summary Survey Measures (SSMs) where each SSM has its own benchmark.
      • Out of these 10, only 8 SSMs will be scored in 2019. The average of these 8 SSMs will determine the performance rate for the CAHPS for MIPS.
      • CAHPS for MIPS will also earn 2 bonus points as it is classified as a Patient Experience (Outcome) Measure.
    4. Calculate Outcome and Other High Priority Measure Bonus Points:
      • If additional high priority measure(s) is/are reported beyond the required outcome measure or other high priority measure, add:
        • +2 bonus points for each additional Outcome Measure or Patient Experience measure.
        • +1 bonus point for each additional High Priority Measure.
      • Bonus points are capped at 10% of the maximum achievement points that can be earned. If maximum points is 60, you can only earn 6 bonus points. Bonus points are awarded for a measure, if the data has met the 70% data completeness, 20 case minimum requirement, and have a performance rate greater than 0% (or more than 1 in the numerator).
      • You may submit more than the required number of measures. CMS will score your top scoring Outcome measure first and then your next 5 highest scoring measures. Anything reported above 6 measures is eligible for bonus points only (no achievement points) if designated as Outcome or High Priority and bonus criteria is met.
    5. Calculate CEHRT Bonus Points (if applicable)
      • Additional bonus points can be earned for reporting the measures in a manner that meets end-to-end electronic reporting criteria.
      • End-to-end means no manual data manipulation from the point of data creation to submission to CMS.
      • CEHRT bonus points are also capped at 10% of the maximum achievement points.
    6. Quality Improvement Scoring:
      • This will be calculated for the eligible clinicians and groups that show improvement in 2020 Quality category performance as compared to 2019 performance.
      • The improvement score will be calculated at the performance category level, so ECs can select different Quality measures in 2019 and 2020.
      • Up to 10 percentage points could be earned for showing an improved performance in the Quality category.
      • The improvement score will be calculated as long as there is a previous year performance to be compared.
      • 30% of maximum possible performance category score will be considered as the minimum baseline. Improvement will be calculated from there. So if a provider earned only 3 quality points in 2020, the quality performance improvement will be calculated on an assumed baseline of 18 points (30% of the the maximum 60 quality points that could be reached in 2020).
      • Bonus points earned in 2020 are not factored in when determining improvement score.
      • Improvement Percent Score  = (increase in quality performance category achievement percent score from prior performance period to current performance period / prior performance period quality performance category achievement percent score) x 10.

    Promoting Interoperability Scoring- PI (can be worth 25% or up to 25 points toward MIPS total score):

    • Must use 2015 Edition Certified EHR Technology (CEHRT) •
    • Performance-based scoring at the individual measure level •
    • Four Objectives for a possible total of 110 points weighted at 25%:
      • e-Prescribing - 10 points
        • Query of Prescription Drug Monitoring Program (PDMP)  - 5 bonus points (optional)
      • Health Information Exchange - 40 points (20 points each for sending and receiving information)
      • Provider to Patient Exchange - 40 points (this measure does not have exclusion criteria)
      • Public Health and Clinical Data Exchange (10 points)
    • How is Total score calculated?:  To calculate your total PI score, you add up the scores from each objective + bonus points (if applicable), multiply by PI weight (25%).  The following are examples of how each objective is scored: 
      •  Example 1 e-prescribing scoring:  example numerator/denominator =  50/100 = .5 x 10 = 5 points for this category.  (another example: Numerator/denominator = 1/100. 1% performance rate = 1 point for this category (.1 x 10 = 1 point)).  This measure is worth up to 10 points unless reweighted.
      • Example 2 Provider to Patient Exchange:  60/100 = .6 x 40 = 24 points for this measure.  This measure is worth up to 40 points unless reweighted.
      • Example 3 HIE objectives (20 points each unless reweighted):
        • Support Electronic Referral Loops by Sending Health Information:  1200/1550 = .774 x 20 = 15 points (rounded down)
        • Support Electronic Referral Loops by Receiving and Incorporating Health Information:  1000/1550 = .645 x 20 = 12.9 (rounded up to 13 points)
      • Example 4 Public Health and Clinical Data Exchange - 10 points for reporting to 2 different data registries.
      • Calculated score from examples above(5+24+15+1 3+10) x .25 = 16.75 (out of a possible 25 PI points). Note:  This scenario assumes no bonus points from the 1 optional e-prescribing measure which could add 2.5 points to this score.
      • Exclusions can be claimed for the following base measures:  E-Prescribing, Health Information Exchange and Public Health and Clinical Data Exchange. If exclusions are claimed, the points for excluded measures will be reallocated to other measures:
        • E-prescribing exclusion: 10 points are redistributed equally among HIE making each measure 25 (vs. 20) points.  Note that the bonus measure does not have exclusions since it is optional.
        • Support Electronic Referral Loops by Receiving and Incorporating Health Information exclusion:  The 20 points are redistributed to the Support Electronic Referral Loops by Sending Health Information making it 40 points (vs. 20).
        • Support Electronic Referral Loops by Sending Health Information exclusion: redistributes the points to Provider to Patient Exchange objective making it worth 60 points (vs. 40).
        • Public Health and Clinical Data Exchange Exclusion:  If you meet and claim an exclusion for one of the measures you can still receive 10 points for the objective.  If you meet and and claim an exclusion for 2 measures in this objective, the 10 points would be redistributed to Provider to Patient Exchange objective making this measure worth 50 points.
      • Note that Security and Risk analysis is required but has no point value.
    • To earn a score for the Promoting Interoperability performance category, you must:
      • Use CEHRT for the performance period (90-days or greater)
      • Submit a “yes” to the Prevention of Information Blocking Attestation
      • Submit a “yes” to the ONC Direct Review Attestation
      • Submit a “yes” for the security risk analysis measure
      • Report the required measures under each Objective or claim any applicable exclusions
      • Each measure is scored on performance based on the submission of a numerator and denominator or a “yes or no”
      • Must submit a numerator of at least 1 or a “yes” to fulfill the required measures
      • The scores for each of the individual measures are added together to calculate a final score
      • If exclusions are claimed, the points will be allocated to other measures

    IA Scoring (can be worth 15% or up to 15 points of total MIPS score):

    • You have to attest that you completed, for a minimum of 90 days, one or more Improvement Activities.
    • You can earn a maximum of 40 points for this category (carries 15% weight towards the final MIPS score).
    • Improvement Activities are divided into medium-weight and high-weight activities.
    • High-weight activities carry twice the weight of the medium-weight activities, and therefore count twice as much towards the final MIPS score.
    • Small Practices (and non-patient facing, rural, underserved) are awarded double the points for both the medium-weight and high-weight activities, thus reducing the number of activities that they need to report.
    • The formula to translate the IA performance category percent score into a MIPS score contribution is:
      • Sample score calculation 1 (small practice): 20 (1 medium weighted activity)/40 x .15 x 100= 7.5 points
      • Sample score calculation 2 (large practice): 10 (1 medium weighted activity)/40 x .15 x 100 = 3.75 points

    Cost Scoring (20% or up to 20 points towards total MIPS score):

    • Per MACRA legislation, the combined weight of the Quality and Cost categories must equal 60% of the overall MIPS score. This is true in PY2021 and will remain so in future program years.
    • The Cost category score will be calculated from the Medicare administrative claims. There is no additional data submission required for performance year 2021.
    • The Cost performance category score for 2021 will be calculated based on 3 categories:
      • Medicare Spending Per Beneficiary Clinician (MSPB)
      • Total Per Capita Cost for all attributed beneficiaries
      • 18 episode-based measures
    • Cost is scored very much like Quality, where each measure earns up to 10 measure achievement points via benchmarks based on performance rate. Both the measures will be scored on a decile scale (0-10 points). Benchmarks are based on the performance for the same year.
    • The score will be calculated when the organization meets the case minimum requirement for the two measures: 35 for MSPB and 20 for Total Per Capital Cost.
    • The total available achievement points for Cost is 20.
    • How is Cost performance calculated?: (Total measure achievement points) /(Total available measure achievement points)
    • Sample Score Calculation: 11 (6 out of 10 measure achievement points for the Cost Per Capita measure and 5 out of 10 measure achievement points for the MSPB measure)/20 x 10% x 100 = 5.5 points for Cost Category. (11/20 x .1 x 100 = 5.5)
    • Exception 1: If only one measure (i.e. only MSPB) can be scored, the score on that measure will determine the Cost Category score.
    • Exception 2: If the eligible clinician or group cannot meet the case-minimum for both the Cost category measures, the weight of the Cost category (10%) will be reassigned to the Quality category (50%), making it 60%.

    Bonus Scoring (i.e. What else can be added to my score in PY2021?):

    • Small Practice Bonus
      • Small practices will be awarded 6 additional points in the Quality performance category score of clinicians in small practices.  Organizations can find their small practice status for the 2021 performance year using the CMS MIPS Participation Tool.
    • Complex Patient Bonus (5 points maximum added to final MIPS score)
      • CMS will award up to 5 bonus MIPS points proportional to the level of clinical complexity and risk of a clinician’s patient population.
      • These points are calculated by adding the average Hierarchical Conditions Category (HCC) risk score to the final score.
      • Generally, this will award between 1 to 5 points to clinicians based on the medical complexity of the patients they see.

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    What impact does MIPS have on my Medicare payments and clinical reputation?

    • MIPS eligible clinicians will receive neutral, positive or negative payment adjustments based on their composite performance score (CPS).
    • The maximum negative adjustments is 9% in 2023.
    • The threshold for these payment adjustments will be the mean or median composite score for all MIPS eligible clinicians during the previous performance period. CMS estimates that approximately 572,000 eligible clinicians would be required to participate in MIPS in the 2021 MIPS performance period. Under the proposed rule, the payment adjustment for the 2023 payment year would range from - 9% to +9X% where X is an adjustment factor to allow the MIPS program to stay budget neutral. 2021 MIPS Points adjustments
    • How to read this graph:

      • The figure above is the CMS’ projection for how MIPS scores will translate into Medicare Part B payment adjustments for the 2021 performance year and associated 2023 payment year.
      • Each year, CMS sets a performance threshold (PT) at which a provider earning at least this number of points, will receives 0% adjustment to their Medicare Part B payments – no penalty, no incentive. For program year 2021, CMS set the performance threshold to 60 points (up from 45 in PY 2020).
      • Every incremental tenth-of-a-point corresponds to a proportional change in payment adjustment. The maximum penalty of -9% is assessed if a clinician scores below ¼ of PT (equal to 11.25 points for 2021).
      • If a clinician scores at or above the exceptional performance bonus threshold (EPBT; set to 85 for 2021, as seen in blue in the figure above), then the exceptional bonus is applied in proportion to the amount by which the MIPS score exceeds the EPBT.
      • The MACRA legislation allows CMS to arbitrarily set the PT and EPBT for the new “transition years” through 2021. In 2022, by law the PT must be raised to equal the historical mean or median of scores nationally.
      • The maximum bonus is estimated by CMS to be 4.69% for clinicians that reach a MIPS score of 100 on 2021 MIPS reporting (~$6,100 for a clinician with an average $130,000 of Medicare income).
    • Payments excluded from MIPS payment adjustments:

      • Medicare Part A
      • Medicare Advantage Part C
      • Medicare Part D
      • CAH Method I facility payments
      • Federally qualified health center (FQHC), rural health clinic (RHC), ambulatory surgical center (ASC), home health agency (HHA), hospice, or hospital outpatient department (HOPD) facility payments billed under the facility’s all-inclusive payment methodology or prospective payment system methodology
    • Your MIPS score moves with you!

      • The financial and reputational impacts of the MIPS score are attached to a clinician, even if the clinician changes organizations/practices. For example, if a clinician earns a MIPS score for 2021 and moves to another organization in 2022, the new organization will inherit the MIPS payment adjustment applied in 2023 based on the 2021 score earned by the clinician at the previous organization.
      • In addition, every historical MIPS score earned by a clinician is a permanent part of the publicly-reported record released and maintained by CMS, effectively making MIPS scores an increasingly significant portion of a clinician’s resume.
    • Reputational Impacts:

      • CMS publishes performance measures through its Physician Compare website. MACRA requires CMS to publish each eligible clinician’s annual MIPS score and performance category scores within approximately 12 months after the end of the performance year.
      • PY2020 MIPS scores will be publicly available sometime in 2022, all identifiable by clinician and group.
      • The following 2020 MIPS data are available for public reporting for clinicians and groups: –
        • Quality
        • Promoting Interoperability
        • Improvement Activities
        • Cost
        • Performance category scores
        • Final Score
      • Consumers will be able to see their clinicians rated against national peers on a scale of 0 to 100.
      • A subset of 2020 MIPS quality measures will be reported as measure level star ratings in 2022.MIPS quality star rating
      • Measures reported as star ratings must meet the established public reporting standards. Star ratings and star rating cut-offs must prove to be reliable.

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    What is the minimum MIPS score I have to acheive to avoid a penalty in 2023?

    For 2021 the performance threshold is set at 60 points (increased from 45 in 2020).

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    Is there flexibility within MIPS for Small Practices?

    If reporting as individuals or as a group, and your TIN has 15 or less eligible clinicians (CMS Small Practice Definition: 1-15 eligible clinicians), you might be able to take advantage of flexibility available for small practices in 2021:

    • Small Practice Bonus Points:
      • Small practices will be awarded 6 additional points including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus.
      • You can find your small practice status for the 2021 performance year on the MIPS Participation Status Tool.
    • Hardship Exception for PI:
      • Small Practices can claim hardship exception in 2021 if they encounter overwhelming circumstances and are unable to utilize a certified EHR to fulfill PI category reporting requirements.
      • The deadline for filing this exception is December 31, 2021. When the application becomes available, a link to apply for the exclusion will appear on your dashboard.
      • CMS Exception Applications
    • Data Completeness Requirement (for Quality measures) Not Met
      • A Small Practice will earn 3 points for a measure that fails data completeness of 70% (or has less than 20 in the denominator). Practices with 16 or more eligible clinicians (large practice designation) will not earn any points for measures that are not complete.
    • Double Weight for Improvement Activities
      • Small Practices are awarded double the points for both the medium-weight and high-weight activities which reduces the number they need to report to achieve the full value of this category.

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    How do I get started reporting MIPS through MDinteractive?

    You can report 3 categories of MIPS through MDinteractive:

    • Quality
    • Improvement Activities
    • Promoting Inteoperability (requires use of a 2015 certified EHR)

    This is a summary of the necessary steps:

    • Determine your eligibility
    • Create an account - for no upfront cost - with MDinteractive (if you don’t already have one)
    • Decide if you will be reporting as a group or as individuals
    • Decide which categories of MIPS you will be reporting/attesting to:
      • Quality
        • Pick your Quality measures at MIPS by Specialty or 2021 Quality Measures
        • Determine how you will collect (and then report) your data:
          • Manual entry using available user-friendly software tools
          • Use of excel templates to collect and report data (and then upload to secure file storage area of account
          • Upload EHR files
          • Check with MDinteractive to see if your existing files might be able to be used for reporting Quality data.
      • Promoting Interoperability (PI)
        • Run report for a minimum of 90 day date range from your Certified EHR to get data (numerator/denominator numbers) for at least the base measures.
        • Enter numbers into the PI module of the software for attestation.
      • Improvement Activities (IA)
        • Review list of available Improvement Activities 
        • Choose 40 points worth of activities based on your group size (performed for a minimum of 90 days).  If reporting MIPS as a group, at least 50% of the providers in the TIN must have completed the activity.
        • Log into your account and from the IA module (add/edit), enter at least 90 day date range, find your activities and attest “yes”.

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Register with MDinteractive