CMS Final 2019 MIPS Rules Are Here - What You Need to Know

Posted on November 10, 2018

CMS released the 2019 Quality Payment Program Final Rule on November 1, 2018.  A detailed summary can be found here.  Below are highlights of some of the key provisions for Year 3 of the QPP MIPS program.

More MIPS Eligible Clinicians

In 2019, the definition of MIPS eligible clinicians is expanded to include some additional clinician types:

  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered dietitian or nutrition professionals

While CMS had originally proposed to include Social Workers, the agency decided to remove them from the list of eligible clinicians at this time.

Increased Thresholds to Avoid Penalties and Achieve Bonus

CMS plans to double the MIPS performance threshold in 2019. MIPS eligible clinicians and groups would have to earn at least 30 MIPS points (up from 15 points in 2018) to ensure a neutral payment adjustment.

Additionally, CMS raises the bar for the top MIPS performers. Clinicians and groups seeking an exceptional performance bonus would need to earn at least 75 MIPS points (up from 70 points in 2018).

Higher Payment Adjustments for 2021

Payment adjustments will range from -7% up to 7% in the 2021 payment year. Any positive payment adjustments will be multiplied by a scaling factor to ensure budget neutrality, so the maximum positive adjustment will likely be below 7%.

More Low-Volume Exclusions

Starting in Year 3 of the MIPS program, CMS will add a 3rd criterion for clinicians to qualify for the low-volume threshold. Clinicians and groups must meet one of the following three criteria to be excluded from MIPS:

  • Have $90,000 or less in Part B allowed charges for covered professional services; OR
  • Provide care to 200 or fewer beneficiaries; OR
  • New: Provide 200 or fewer covered professional services under the Physician Fee Schedule (PFS).

Single MIPS Determination Period

There will be a single MIPS determination period for purposes of determining the low-volume threshold and to identify MIPS eligible clinicians as non-patient facing, a small practice, hospital-based, and ASC-based. The determination period includes 2 12-month segments:

  • An initial 12-month segment beginning on October 1, 2017 to September 30, 2018 (including a 30-day claims run out); and
  • A second 12-month segment beginning on October 1, 2018 to September 30, 2019 (does not include a 30-day claims run out).

Remember, if a TIN or TIN/NPI did not exist in the first time period, but does exist in the second, these eligible clinicians could become eligible for MIPS.

Modified Performance Category Weights

The Quality and Cost categories will have different performance weights in 2019. The Quality category will drop from 50% to 45% of the Final MIPS score, while the Cost category will increase to 15%. The category weights for Promoting Interoperability (25%) and Improvement Activities (15%) will remain the same as this year.

The Quality reporting requirements remain mostly the same as 2018. Clinicians will still report 6 Quality measures, with at least 1 being an Outcome measure, or a High Priority measure if an Outcome measure is not applicable. Each measure will be reported on at least 60% of eligible cases for the entire year.

CMS is also adding 8 new Quality measures to report in 2019, while removing 26 measures it found were duplicative of other measures or extremely topped out. A list of these measures can be found here.

Help for Small Practices

Small Practices (15 or fewer in the TIN) will continue to receive a small practice bonus, but it will be included in the Quality performance category score instead of as a stand alone bonus in 2019. The bonus is also increased to 6 points (up from 5 points in 2018) if the clinician submits data on at least 1 Quality measure. Small practices will also continue to receive at least 3 points for quality measures that do not meet the data completeness requirements.

New “Opt-In” Policy

Clinicians or groups would have the ability to “opt-in” to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria. Those clinicians who “opt-in” to the MIPS program would be subject to neutral, negative or positive payment adjustments based on their MIPS performance and final score.

Restructuring of the Promoting Interoperability Category

CMS is overhauling the Promoting Interoperability (PI) category with several major changes:

  • PI remains a minimum 90 day reporting period, however, eligible clinicians would be required to use 2015 Edition of Certified Electronic Health Record Technology (CEHRT) if reporting this category.
  • Base, performance and bonus scores are eliminated and replaced with a new scoring methodology based solely on performance.
  • There are four objectives MIPS eligible clinicians must meet: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Clinicians would be required to report certain measures from each of the four objectives, unless an exclusion is claimed.
  • The Security Risk Analysis measure will still be a required measure, but without points.
  • Two new measures are added for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as optional with bonus points available.
  • CMS also maintains the hardship exemption for this performance category.

Multiple Submission Types

CMS would allow MIPS eligible clinicians and groups to submit quality measures via multiple submission types (new MIPS term for “submission mechanism”). If the same measure is submitted via multiple collection types, the one with the greatest number of points will be used for scoring. The multiple-submission type option would not apply to submissions using the CMS web-interface.

Large practices (16 or more in the TIN) will no longer be able to report via Medicare Part B claims.

Moving Forward

The provider community will see some major changes to the MIPS program next year. The CMS 2019 Final Rule will require more types of clinicians to report MIPS, and increase penalties for MIPS eligible clinicians who choose not to report or who fail to meet the new minimum performance threshold of 30 points.

MDinteractive will continue to post updates to our website so you can stay informed and learn how to successfully report MIPS for the new performance year. In the meantime, the 2018 MIPS reporting year is well underway, so clinicians and groups should continue to focus their efforts on meeting the current reporting requirements. Note:

This article was originally posted on August 8, 2018, to summarize the key provisions of the 2019 Proposed Regulation. It has been updated to reflect the changes included in the 2019 Final Regulation released on November 1, 2018.

MACRA 2019 MIPS Final Rule CMS Final Rule

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