The 2023 Quality Payment Program Proposed Rule is Here - Learn What Changes are Ahead for MIPS Reporting

Posted on August 2, 2022
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The Centers for Medicare and Medicaid Services (CMS) released its Medicare Physician Fee Schedule (PFS) Proposed Rule on July 7, 2022, which includes proposed changes to the Quality Payment Program (QPP) for 2023 and future performance years. The proposed rule provides policy updates to the traditional Merit-based Incentive Payment System (MIPS) program, the new MIPS Values Pathway (MVPs) framework, Alternative Payment Models (APMs), and Accountable Care Organizations (ACOs). A 60-day comment period will be open until September 6, 2022. The proposal could go through additional changes before a final regulation is issued sometime in November. 

Minimal Proposed Changes to Traditional MIPS

The proposed rule would continue to use the mean final score from the 2017 performance year to establish the performance threshold for the 2023 performance year of 75 MIPS points. This means clinicians and groups would need to reach 75 MIPS points again in 2023 to avoid a negative payment adjustment in the 2025 payment year. 

As finalized in the  2022 MIPS Final Rule, there will no longer be an additional performance threshold for exceptional performance in 2023. The 2022 performance year is the last year clinicians can earn an exceptional performance bonus.  

CMS is not proposing any changes to the MIPS performance category weights in 2023 and will maintain the performance category redistribution policies for small practices (15 or fewer clinicians). The points from each category are added together to give a MIPS final score.

CMS will continue to automatically reweight the Promoting Interoperability performance category and more heavily weight the Improvement Activities performance category for small practices. When both Cost and Promoting Interoperability are reweighted, Quality and Improvement Activities will each be weighted at 50%.

The proposed payment adjustments for 2025 outlined in the table below reflect the removal of the additional adjustment for exceptional performance. MIPS scores at or below 18.75 points would earn the full -9 percent penalty.

Final Score 2023Payment Adjustment 2025
75.01 - 100 pointsPositive payment adjustment greater than 0%
75 pointsNeutral payment adjustment
18.76 -74.99 pointsNegative payment adjustment between -9% and 0%
0 - 18.75 pointsNegative payment adjustment of -9%

Quality Category Proposed Updates

CMS is not proposing any changes to the data completeness requirements in 2023, so clinicians will report at least 70% of eligible encounters for the quality measures they report, regardless of insurance type, for the 2023 calendar year. However, this threshold would increase  to 75% for the 2024 and 2025 performance years under the proposal. 

There are a number of quality measure changes, including expansion of the definition of “high priority measure” to include health equity-related quality measures. CMS is proposing a total of 194 quality measures for the 2023 performance period which reflects:

  • Substantive changes to 75 existing quality measures;
  • The addition of 9 new quality measures (which includes one new administrative claims measure);
  • Removal of 15 quality measures; and 
  • Addition/removal of quality measures from specialty sets.  

CMS is also proposing to remove measures #110: Preventive Care and Screening: Influenza Immunization and #111: Pneumococcal Vaccination Status for Older Adults from the traditional MIPS program but would retain them for MVPs. Measure #110 would also be retained for purposes of Medicare Shared Savings Program (MSSP) ACO reporting through the APM Performance Pathway (APP). The rational for removing these measures from traditional MIPS is due to the proposed new Adult Immunization Status measure for future reporting.

Measures that have been added to or removed from the 2023 Quality measure inventory, along with their collection types, are outlined in the tables below.

Proposed New Quality MeasuresCollection Type
Psoriasis – Improvement in Patient-Reported Itch SeverityMIPS Clinical Quality Measure (CQM)
Dermatitis – Improvement in Patient-Reported Itch SeverityMIPS CQM
Screening for Social Drivers of HealthMIPS CQM
Kidney Health EvaluationElectronic CQM (eCQM) and MIPS CQM
Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) TherapyMIPS CQM
Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint InhibitorsMIPS CQM
Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaMIPS CQM
Adult Immunization StatusMIPS CQM
Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment SystemAdministrative Claims*

*CMS is proposing to use performance period benchmarks exclusively for scoring administrative claims measures.

Proposed Quality Measures to be Removed Collection Type
#76 Prevention of Central Venous Catheter (CVC) - Related Bloodstream InfectionsMedicare Part B Claims, MIPS CQM
#119 Diabetes: Medical Attention for NephropathyeCQM, MIPS CQMs
#258 Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)MIPS CQM
#260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)MIPS CQM
#261 Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessMedicare Part B Claims, MIPS CQM
#265 Biopsy Follow-UpMIPS CQM
#275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyMIPS CQM
#323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)MIPS CQM
#375 Functional Status Assessment for Total Knee ReplacementeCQM
#425 Photodocumentation of Cecal IntubationMIPS CQM
#439 Age Appropriate Screening ColonoscopyMIPS CQM
#455 Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)MIPS CQM
#460 Back Pain After Lumbar FusionMIPS CQM
#469 Functional Status After Lumbar FusionMIPS CQM
#473  Leg Pain After Lumbar FusionMIPS CQM

 

Proposed Quality Measures to be Removed from Traditional MIPS*Collection Type
#110: Preventive Care and Screening: Influenza ImmunizationMedicare Part B Claims, eCQM, 
MIPS CQM
 
#111: Pneumococcal Vaccination Status for Older AdultsMedicare Part B Claims, eCQM, MIPS CQM

*These measures would still be available for MVP reporting. Measure  #110 would also be retained for MSSP ACO reporting through the APP. When reporting under traditional MIPS, a new proposed Adult Immunization Status measure would include influenza and pneumococcal vaccination, as well as Td/Tdap and Zoster vaccination.

Previously Finalized Quality Updates for 2023:

In the 2022 MIPS Final Rule several policy changes were adopted that go into effect beginning with the 2023 performance period:

  • Measures with a benchmark - The 3-point floor is removed for measures that can be scored against a benchmark. These measures will receive 1-10 points. (This does not apply to new measures in the first 2 performance periods available for reporting.)
  • Measures without a benchmark - The 3-point floor is removed for measures without a benchmark (except small practices). These measures will receive 0 points (small practices will continue to earn 3 points). (This does not apply to new measures in the first 2 performance periods available for reporting or to administrative claims measures.)
  • Measures that don’t meet case minimum requirements (20 cases) - The 3-point floor is removed (except small practices). These measures will earn 0 points (small practices will continue to earn 3 points). (This does not apply to new measures in the first 2 performance periods available for reporting or to administrative claims measures. Measures calculated from administrative claims are excluded from scoring if the case minimum is not met.)

Improvement Activities Category Proposed Updates

There are no major proposed changes to the MIPS Improvement Activities (IA) category other than updates to the IA inventory. CMS is proposing to add four new activities, modify five current activities, and remove five existing improvement activities from the IA inventory as outlined in the following table.

Proposed New Improvement ActivitiesImprovement Activities Proposed for Removal
IA_AHE_XX Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data (Medium)IA_BE_7 Participation in a QCDR, that promotes use of patient engagement tools
IA_AHE_XX Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients (High)IA_BE_8 Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive
IA_EPA_XX Create and Implement a Language Access Plan (High)IA_PM_7 Use of QCDR for feedback reports that incorporate population health
IA_ERP_XX COVID-19 Vaccine Achievement for Practice Staff (Medium)IA_PSPA_6 Consultation of the Prescription Drug Monitoring program
 IA_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
 IA_PSPA_30 PCI Bleeding Campaign

Promoting Interoperability Category Proposed Updates

CMS proposes to make several changes to the Promoting Interoperability (PI) category. The proposed updates would:

  • Require and modify the Electronic Prescribing Objective’s Query of Prescription Drug Monitoring Program (PDMP) measure.
  • Expand the Query of PDMP measure to include not only Schedule II opioids, but also Schedule III, and IV drugs.
  • Add a new Health Information Exchange (HIE) Objective option, the Enabling Exchange under the Trusted Exchange Framework and Common Agreement (TEFCA) measure (requiring a yes/no response), as an optional alternative to fulfill the objective.
  • Consolidate the current options from three to two levels of active engagement for the Public Health and Clinical Data Exchange Objective and require the reporting of active engagement for the measures under the objective.
  • Continue to reweight the PI category for certain types of non-physician practitioner MIPS eligible clinicians.

CMS would discontinue automatic reweighting for the following clinician types beginning with the 2023 performance period:

  • Nurse practitioners
  • Physician assistants
  • Certified registered nurse anesthetists 
  • Clinical nurse specialist

The agency plans to continue automatic reweighting for the following clinician types in the 2023 performance period:

  • Clinical social workers
  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists, and 
  • Registered dieticians or nutrition professional

When participating in MIPS at the APM Entity level (reporting the APP, traditional MIPS or an MVP), CMS proposes to allow APM Entities to report PI data at the APM Entity level. APM Entities would still have the option to report this performance category at the individual and group level.

CMS proposes to update PI scoring for each of the PI measures as follows:

PI ObjectiveMeasureMaximum Points
Electronic 
Prescribing
e-Prescribing10 points
Query of PDMP10 points
Health 
Information 
Exchange
Support Electronic Referral Loops by Sending Health Information15 points
Support Electronic Referral Loops by Receiving and Reconciling Health Information15 points
OR
Health Information Exchange Bi-Directional Exchange*30 points
OR
Participation in TEFCA30 points
Provider to Patient ExchangeProvide Patients Electronic Access to Their Health Information25 points
Public Health and Clinical Data ExchangeReport the following 2 measures:
  • Immunization Registry Reporting
  • Electronic Case Reporting
25 points
Report one of the following 
measures:
  • Syndromic Surveillance Reporting
  • Public Health Registry Reporting
  • Clinical Data Registry Reporting
5 points (bonus)

Cost Category Proposed Updates

A maximum cost improvement score of one percentage point out of 100 percentage points would be established for the Cost performance category.  It would be retroactively applied starting with the current 2022 performance period. 

Complex Patient Bonus

CMS is proposing that a facility-based MIPS eligible clinician would be eligible to receive the complex patient bonus, even if they don’t submit data for at least one MIPS performance category.

MIPS Value Pathways (MVPs) 

As previously finalized in the 2022 MIPS final rule, CMS will make MVPs available for reporting gradually, beginning with the 2023 performance year: 

  • 2023, 2024, and 2025 performance years - Individual clinicians, single specialty groups, multispecialty groups, subgroups, and APM Entities can report MVPs. 
  • 2026 performance year and for future years - Individual clinicians, single specialty groups, subgroups, and APM Entities can report MVPs.

The proposed rule continues to focus on the development of MVPs and subgroup reporting. CMS is introducing five new MVPs in the proposed rule for reporting in 2023 and proposing revisions to seven MVPs it finalized last year.

Proposed New MVPsProposed Revisions for Previously Adopted MVPs
Advancing Cancer CareAdvancing Care for Heart Disease MVP
Optimal Care for Kidney HealthCoordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP
Optimal Care for Patients with Episodic Neurological ConditionsOptimizing Chronic Disease Management MVP
Supportive Care for Neurodegenerative ConditionsAdvancing Rheumatology Patient Care MVP
Promoting WellnessImproving Care for Lower Extremity Joint Repair MVP
 Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP
 Patient Safety and Support of Positive Experiences with Anesthesia MVP

Subgroup Registration

CMS previously finalized that clinicians who choose to participate in a subgroup to report an MVP must register as a subgroup between April 1 and November 30 of the performance year. In addition to the required MVP registration information*, the subgroup registration must include:

  • A list of Taxpayer Identification Number (TIN)/National Provider Identifier (NPIs) in the subgroup;
  • A plain language name for the subgroup (which will be used for public reporting).

CMS is proposing to add a 3rd requirement to the subgroup registration to include:

  • A description of the composition of the subgroup, which may be selected from a list or described in a narrative.

The proposed rule would also permit a clinician (identified by NPI) to register for one subgroup per TIN.

Subgroup Eligibility

CMS proposes to use the first segment of the MIPS determination period to determine the eligibility of clinicians intending to participate and register as a subgroup. As previously finalized, each subgroup must include at least one MIPS eligible clinician.

Subgroup Scoring

CMS is proposing to calculate and score administrative claims measures at the TIN level, not at the subgroup level:

  • Foundational Layer (MVP Agnostic) - For each selected population health measure in an MVP, subgroups would be assigned the affiliated group’s score, if available. In instances where a group score is not available, each such measure would be excluded from the subgroup’s final score.
  • Quality Performance Category - For each selected outcomes-based administrative claims measure in an MVP, subgroups would be assigned the affiliated group’s score, if available. In instances where a group score is not available, each such measure would be assigned a zero score.
  • Cost Performance Category -  Subgroups would be assigned the affiliated group’s cost score, if available for the cost performance category in an MVP. In instances where a group score is not available, each such measure would be excluded from the subgroup’s final score.

Subgroup Final Score

CMS would not assign a score for a subgroup that registers but does not submit data as a subgroup.

Advanced APMs 

CMS is proposing policies to encourage participation in Alternative Payment Models (APMs). The proposal would:

  • Remove the 2024 expiration of the 8% minimum on the Generally Applicable Nominal Risk standard for Advanced APMs and make the 8% minimum permanent.
  • Apply the 50 clinician limit to the APM Entity participating in the Medical Home Model. The proposal would identify the clinicians in the APM Entity by using the TIN/NPIs on the participation list of the APM Entity on each of the three QP determination dates (March 31, June 30, and August 31). This policy would become effective in performance year 2023.

CMS is also seeking comment on transitioning to making QP threshold determinations at the clinician, rather than Advanced APM Entity level, in the future. 

Medicare Shared Savings Program (MSSP) 

Some of the proposals that would impact MSSP Accountable Care Organizations (ACOs) include:

  • Giving ACOs more time before advancing to the highest levels of risk.
  • Providing advance shared savings payment (“advance investment payments”) to low-revenue ACOs inexperienced with risk that serve underserved populations, including an upfront fixed payment and quarterly payments adjusted for beneficiaries’ social risk.
  • Reinstating a sliding scale approach for determining shared savings for ACOs, regardless of how they report quality data.
  • Establishing a health equity bonus to reward ACOs that report all-payer eCQMs/MIPS CQMs and serve a high proportion of underserved beneficiaries. The proposed adjustment would add up to 10 bonus points to the ACO’s MIPS quality performance category score. 
  • Extending the incentive for reporting eCQMs/MIPS CQMs through performance year 2024 to align with the sunsetting of the CMS Web Interface reporting option.
  • Changing certain aspects of its benchmarking methodologies aimed at improving participation among providers who treat a high percentage of beneficiaries with substantial clinical risk factors and dually eligible beneficiaries.

Next Steps

Clinicians should become familiar with the proposed QPP changes as outlined in the 2023 Medicare PFS Proposed Rule so they understand the potential impact on their reporting practices next year. The public can submit comments on the proposed policy updates through September 6, 2022, and a final regulation is expected to be released in November. 

MDinteractive will continue to post updates to our website so clinicians can stay informed of program changes. In the meantime, the 2022 MIPS reporting year is well underway, so clinicians and groups should continue to focus their efforts on meeting the current reporting requirements.

 

2023 MIPS Proposed Rule 2023 QPP Proposed Rule Medicare Physician Fee Schedule (PFS) Proposed Rule 2023 MVPs

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