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MIPS: Making Sense of Your Cost Score

Posted on October 23, 2019
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Cost is the fourth performance category under the MIPS program and makes up 15% of your total MIPS score for 2019 (up from 10% in 2018 and 0% in 2017). This category will steadily increase to 30% by the year 2022 when it will have the same weight as Quality. If CMS is unable to calculate a Cost score for a clinician, the category will be reweighted to Quality. While clinicians can relatively quickly change their MIPS Quality score by tracking some specific outcomes (e.g., track smoking status and give cessation advice), Cost is more challenging. It is more complex with many different variables, so monitoring Cost becomes important as it contributes more towards your final MIPS score. MDinteractive can help you access your CMS performance feedback reports which will provide your Cost score from prior MIPS reporting years.  In this article we will explore the different cost measures, how they are scored and the potential impact on your practice.

What is the Cost Category?

The MIPS Cost category, which replaced the former Value Based Modifier (VBM) program, compares the cost of care a clinician provides to Medicare beneficiaries to a national benchmark. CMS calculates the Cost component of MIPS based on Medicare claims submitted during the MIPS performance year (e.g., January 1, 2019 through December 31, 2019 for the 2019 performance year). This means clinicians have no data submission or reporting requirements for this category.

What are the Cost Measures?

Even if you didn’t receive a Cost score in the past, you could in 2019 or future years as more cost measures are added to this category. Last year, CMS calculated the Cost score based on 2 measures - the Medicare Spending Per Beneficiary (MSPB) measure and the Total Per Capita Cost (TPCC) measure. For 2019, Cost scores will continue to be based on these measures, in addition to 8 new episode-based measures. Each cost measure has specific eligible case minimums that must be met for the measure to receive a score. Let’s take a closer look at each of the measures below.

  • Medicare Spending Per Beneficiary (MSPB) - This measure calculates the cost of services (Medicare Parts A and B claims) provided by a clinician during an MSPB episode (the period 3 days prior to, during, and 30 days following an inpatient hospital stay) and compares these costs to expected costs. The costs get attributed to the clinician with the most Medicare Part B charges during the episode. A clinician must have a minimum of 35 eligible cases for the MSPB score to be calculated.
  • Total Per Capita Cost (TPCC) - This measure calculates the overall cost of care (Medicare Parts A and B claims) provided to a beneficiary who received primary care services during the performance period. This measure typically affects primary care and internal medicine clinicians, however, it could be assigned to a specialist if the specialist provided more primary care services to the patient. A clinician must have a minimum of 20 eligible cases for the TPCC measure.
  • 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) and have case minimum requirements as outlined in the table below.

Episode-Based Measure

Measure Type

Minimum Number of Cases

Elective Outpatient Percutaneous Coronary Intervention (PCI)

Procedural

10

Knee Arthroplasty

Procedural

10

Revascularization for Lower Extremity Chronic Critical Limb Ischemia

Procedural

10

Routine Cataract Removal with Intraocular Lens (IOL) Implantation

Procedural

10

Screening/Surveillance Colonoscopy

Procedural

10

Intracranial Hemorrhage or Cerebral Infarction

Acute inpatient medical condition

20

Simple Pneumonia with Hospitalization

Acute inpatient medical condition

20

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

Acute inpatient medical condition

20

How is the Cost Category Scored?

The Cost category accounts for 15% of your total MIPS score in 2019. In order to receive a score for this category, you must meet case minimum requirements for at least one cost measure. If you don’t have enough eligible cases for one measure, you could be scored on the remaining cost measures. The category will be reweighted to Quality, however, if you do not meet the case minimum for any of the cost measures. This means Quality would be weighted at 60% of your MIPS score and Cost would be weighted at zero.

If you report MIPS as an individual clinician, you will receive an individual Cost score at the NPI and TIN level.  If you report MIPS as a group, you will receive one Cost score for the entire group at the TIN level.

Each cost measure will receive between 1 - 10 points based on your performance in the measure compared to national benchmarks. The Cost category benchmarks for each measure are based on the current performance year data. CMS calculates the Cost category score by adding the points scored on each measure and dividing by the total possible points available.

Scoring Example:

As an example, the illustration below shows how the Cost category would be calculated in 2019 if a clinician is scored on just 3 of the cost measures:

MeasureMIPS PointsTotal Possible Points
MSPB5 points10 points
TPCC6 points10 points

Screening/Surveillance Colonoscopy

8 points10 points
Total19 points30 points

Cost Performance Score: 19 divided by 30 = 0.63 points (or a performance rate of 63%)

Total Cost Score: (0.63 [Cost points] x 0.15 [Cost weight]) x 100 = 9.45 Cost Points

In this example, the clinician would receive a total Cost score of 9.45 MIPS points based upon his or her performance in the 3 cost measures.

Understanding Your Scores and Ways to Improve

The first step is to review your 2018 CMS performance feedback report. This will tell you if you received a Cost score for the 2018 MIPS reporting year. MDinteractive can obtain your CMS performance feedback report for you and help analyze your Cost data. Just click on the “QPP Performance Feedback” button from your MDinteractive account dashboard and follow the steps or view this article for additional instructions.

While CMS uses claims data to calculate your Cost score, there are some steps you can take to support success in this category:

  • Ensure you are documenting diagnosis codes correctly in your patient records and on your claims. CMS considers comorbid conditions when calculating the cost of care for beneficiaries whose care and treatment are more complex.
  • Review costs associated with individual clinicians in your practice if you are reporting as a group to better understand clinical care decisions and make necessary practice improvements.
  • Review the Choosing Wisely lists. These were created by national medical specialty societies and represent specific, evidence-based recommendations clinicians and patients should discuss. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.
  • Make sure your patients are vaccinated. Each year our country spends nearly $27 billion treating adults for diseases that could have easily been prevented through vaccinations.
  • Use shared decision-making tools to reduce unnecessary procedures.

Stay Informed

The Cost category accounts for 15% of your MIPS score in 2019, and will continue to grow until it is equally weighted with Quality in 2022 (both categories will be weighted at 30% that year). While you don’t have to submit any data for this category (it is automatically included as part of your claims submission), it is important to understand your Cost score as it will become even more important in future years. This year the category will include a total of 10 Cost measures, but you will only be scored on a measure if you meet the measure’s case minimum requirements. Consider taking steps to support your success in this important category. MDinteractive can assist you with getting your CMS performance feedback report so you can track your Cost score and its impact on your practice.

MIPS MACRA MIPS Reporting Cost Category Cost Measures MIPS Scores

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