MIPS Cost Performance Category

Ten cost measures are used to evaluate performance in the Cost performance category in the 2019 MIPS 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.

  • Medicare Spending Per Beneficiary (MSPB)

The Medicare Spending Per Beneficiary (MSPB) measure evaluates solo practitioners and groups on their spending efficiency and is risk-adjusted to account for patients' risk profiles. Solo practitioners and groups are identified by their National Provider Identification (NPI) and Taxpayer Identification Number (TIN) combination. Specifically, the MSPB measure assesses the average spend for Medicare services performed by providers/groups per episode of care. Each episode comprises the period immediately prior to, during, and following a patient's hospital stay. Each beneficiary MSPB episode is attributed to a single TIN-NPI.

The episode is attributed to the MIPS eligible clinician who billed the plurality  of Medicare Part B claims, measured by allowed charges, during the period between the index admission date and the discharge date.

  • Total Per Capita Costs (TPCC)

The Total Per Capita Costs (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN). On the attribution logic to TPCC there are 2 steps:

Step 1: If a beneficiary received more primary care services from an individual TIN-NPI that is classified as either a primary care physician (PCP), nurse practitioner (NP), physician assistant (PA) or clinical nurse specialist (CNS) than from any other TIN-NPI during the performance period, then the beneficiary is attributed to that TIN-NPI.

Step 2: If a beneficiary did not receive a primary care service from a TIN-NPI classified as either a PCP, NP, PA or CNS during the performance period, then the beneficiary may be assigned to a TIN-NPI in "Step 2."

 

  • 8 Episode-Based Measures (new for 2019)

These measures assess the cost of care (Medicare Parts A and B claims) that are related to a specific episode of care for a clinical condition or procedure.  The measures are categorized into "episode groups" (e.g., procedural episodes or acute inpatient medical condition episodes).  

Episode-Based MeasureMeasure Type

Elective Outpatient Percutaneous Coronary Intervention (PCI)

Procedural

Knee Arthroplasty

Procedural

Revascularization for Lower Extremity Chronic Critical Limb Ischemia

Procedural

Routine Cataract Removal with Intraocular Lens (IOL) Implantation

Procedural

Screening/Surveillance Colonoscopy

Procedural

Intracranial Hemorrhage or Cerebral Infarction

Acute inpatient medical condition

Simple Pneumonia with Hospitalization

Acute inpatient medical condition

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

Acute inpatient medical condition

Benchmarks

CMS will establish a single, national benchmark for each cost measure. These benchmarks are based on the performance period, not a historical baseline period. As a result, CMS can’t publish the actual numerical benchmarks for the cost measures before the start of each performance period. For example, the MSPB benchmark used to determine a MIPS eligible clinician’s 2019 Cost performance category score will be based on CY 2019 claims data. All MIPS eligible clinicians that meet or exceed the case minimum for a measure are included in the same benchmark. Case minimums for each cost measure are identified below.

  • MSPB - A clinician must have a minimum of 35 eligible cases.
  • TPCC - A clinician must have a minimum of 20 eligible cases.
  • Episode-based measures - The minimum case volume for procedural episode-based measures is 10.  The minimum case volume for acute inpatient medical condition episode-based measures is 20.

 

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