In this lesson, we'll take a closer look
at the MIPS pathway for 2018
participation in the Quality Payment
Program. As previously mentioned, MIPS
adjusts clinician payment based on four
performance categories including Quality,
Cost, Improvement Activities and
Promoting Interoperability. For Year 2
of the program or 2018, there are weights
assigned for each of the four
performance categories under MIPS.
Quality is worth 50 points, Cost is worth
10 points, Improvement Activities is
worth 15 points, and Promoting
Interoperability is worth 25 points. You
may notice changes in 2018 for the Cost
and Quality performance categories. In
the 2017 transition year, the Cost
performance category was worth zero
points and the Quality category was
worth 60 points. Points from each
performance category are added together
to compute a MIPS final score, for which
there are 100 possible points. The MIPS
final score is then compared to the MIPS
performance threshold to determine if
you receive a positive, negative or
neutral payment adjustment in payment
year 2020. Let's take a look at what
types of clinicians are eligible to
participate in MIPS for Year 2. The
exact same types of clinicians who are
able to participate during the 2017
transition year are eligible for
participation in Year 2. MIPS eligible
clinicians include physicians, physician
assistants, nurse practitioners, clinical
nurse specialists, and certified
registered nurse anesthetists. As a
reminder, physician not only refers to
doctors of medicine but also doctors of
Osteopathy, dentists, podiatrists,
optometrists and chiropractors. In
continuing to look at who is included in
MIPS for Year 2 of the Quality Payment
Program, let's look at the changes for
the low volume threshold. As you may
recall, for Year 1 of the program, or
2017, the low volume threshold
exclusion applied to clinicians with
Medicare Part B allowable charges less
than $30,000 and who saw less than 100
patients. For Year 2 of the program in
2018, the low volume threshold has been
increased which allows for additional
clinicians to be excluded from the
program. CMS understands that challenges
exist for certain types of practices,
particularly small practices in their
ability to participate in the Quality
Payment Program. So in 2018, MIPS eligible
clinicians with less than $90,000 of
Medicare physician fee schedule
allowable charges and who see less than
200 Medicare patients a year are
excluded from the program. As in 2017,
voluntary reporting remains an option in
2018 for those clinicians who are exempt
from MIPS. In addition to the low volume
threshold exemption, there are two other
basic exemption criteria that exists for
MIPS in 2018 that were also present in
2017. One exemption is if the clinician
is newly enrolled in Medicare during the
performance period of 2018. This means he
or she does not have to participate for
that year.
There are also exclusions for clinicians
who have significant participation in an
Advanced Alternative Payment Model or an
Advanced APM. Significant participation
in an Advanced APM means the clinician
receives 25% of their Medicare payments
or sees 20% of their Medicare patients
through an Advanced APM. There are
special statuses that apply to certain
types of MIPS eligible clinicians in
Year 2. Meeting certain special status
criteria allows for MIPS eligible
clinicians to participate in MIPS with
different requirements. One special
status for example is being considered a
non-patient facing clinician. Non-patient
facing clinicians will automatically
have their Advancing Care Information
performance category re-weighted to 0.
The 25% weight of the Advancing Care
Information performance category will be
shifted to the Quality performance
category. Generally, this applies to
pathologists, certain types of
radiologists, anesthesiologists, and
nuclear medicine clinicians. The criteria
to be considered non-patient facing for
individuals and for groups has not
changed for 2018 and remains the same in
2017. For individuals non-patient facing
means the clinician has less than or
equal to 100 patient facing encounters
during the 2018 performance period. For
groups, that means the group has greater
than 75% of its NPI's billing under the
group's TIN labeled as non-patient
facing during the 2018 performance
period. What is new for Year 2 or 2018 is
criteria on how non-patient facing will
apply to clinicians who choose to
participate as part of a virtual group.
Virtual groups with greater than 75% of
their NPI's billing under the group's
TIN labeled as non-patient facing during
the performance period will qualify for
this special status. We will discuss
virtual groups in more detail later in
this course.
Another special status applies with the
designation of being considered a small
practice. Under the Quality Payment
Program, whether you participate in MIPS
or as part of an Advanced APM, a small
practice is defined as a practice with
15 or fewer MIPS eligible clinicians.
Also the status of being located in a
rural and/or health professional
shortage area remains the same in 2018
as it was in 2017. That is, an individual
MIPS eligible clinician, a group, or a
virtual group with multiple practices
under its TIN or TINs within a virtual
group, with more than 75% of NPI's
billing under the individual MIPS
eligible clinician or groups TIN or
within a virtual group in a zip code
designated as a rural area or health
professional shortage area (HPSA). These
special status designations under the
Quality Payment Program
provide provisions for certain eligible
clinicians to have slightly different
program requirements. For example, if you
are in a practice that is in a rural
area or HPSA area, your requirements for
the Improvement Activities performance
category are scaled down but with the
same amount of points available toward
your final score. Two other changes for
2018 that were not available during the
2017 transition year are bonuses for
complex patients and the small practice
bonus. The complex patient bonus of up to
5% is available for MIPS eligible
clinicians who treat complex patients.
This criteria is based on a combination
of the Hierarchal Condition Categories
and the number of dually eligible
patients treated. The small practice
bonus will add 5 points to any MIPS
eligible clinician in a small practice
as defined as 15 or fewer MIPS eligible
clinicians. The MIPS eligible clinician
or group must submit data on at least
one performance category during the 2018
performance period. Let's take a quick
look at the MIPS Year 2 timeline. The
2018 performance period began on January
1st 2018. Clinicians will care for
patients and record data during the year.
The 2018 performance period ends
December 31st 2018 and all data for the
performance categories must be submitted
no later than March 31st 2019. CMS will
then issue feedback reports during 2019
and Medicare Part B claims will begin
being adjusted on January 2020. A few
more notes to mention about the Year 2,
2018 performance period. For the 2017
transition year, MIPS eligible clinicians
had several participation options
available known as “pick your pace.” This
allowed them to determine the extent to
which they participated in MIPS during
the first year.
MIPS eligible clinicians could report
anywhere from less than
ninety days of data up to a full year. In
2018, the performance period has been
modestly increased to ensure that MIPS
eligible clinicians are prepared for
future program years. For Year 2, MIPS
eligible clinicians will need to report
twelve months for the Quality and Cost
performance categories and 90 days for
Promoting Interoperability and
Improvement Activities performance
categories. Now let's look at the three
ways to report to MIPS in 2018. The first
two options, participating as an
individual or participating as a group,
are exactly the same as they were for
the 2017 transition year. Individual
participation is based off the unique
national provider identifier, or NPI, and
tax identification number or TIN.
Participating as a group is where two or
more clinicians have reassigned their
billing rights over to the TIN. Group
participation may also be as an
Alternative Payment Model or APM. New for
2018 is a way of participating in MIPS
as part of a virtual group. Let's take a
look at more details about virtual group
participation.
Virtual groups are made up of clinicians
or either solo practitioners or a group
with ten or less clinicians that
virtually form a group for purposes of
participating and reporting in the MIPS
program. There are no restrictions on the
types of specialties that can form a
virtual group or the location of the
practices. To be eligible to join or form
a virtual group, you need to be a solo
practitioner who exceeds the low volume
threshold individually, and are not a
newly Medicare enrolled eligible clinician
in 2018, a Qualifying APM participant or
QP or a partial QP choosing not to
participate in MIPS. Alternatively, you
can also be a group that has 10 or fewer
MIPS eligible clinicians and exceeds the
low-volume threshold at the group level.
Solo practitioners and groups who wish
to form a virtual group must have
completed the election process. Virtual
group elections must occur prior to the
beginning of the performance period and
cannot be changed once the performance
period begins. The election period was
October 11th through December 31st 2017
for the 2018 MIPS performance period. In
general, policies that apply to groups in
MIPS will also apply to virtual groups.
Virtual groups use the same submission
mechanisms as groups participating in
MIPS for Year 2. All clinicians within
a TIN are considered part of the virtual
group and data is aggregated for each
performance category to be scored as a
virtual group under MIPS. Lastly, let's
review the data submission mechanisms
for MIPS in 2018. There is no change in
the data submission mechanisms available
for Year 2 of MIPS relative to the
2017 transition year. For the Quality
performance category, individuals may
submit using a qualified clinical data
registry or QCDR, a qualified registry,
the electronic health record or EHR, or
by claims. Groups, including virtual ones,
may submit using the QCDR,
qualified registry,
EHR, or CMS Web Interface for groups of
25 or more.
There is no submission required on
behalf the MIPS eligible clinician for
the Cost performance category. CMS will
calculate the cost score based on
administrative claims. Improvement
Activities and Promoting
Interoperability performance category
data may be submitted by individuals
using attestation, a QCDR, qualified
registry, or EHR. Groups may submit the
data by attestation, QCDR,
qualified registry, EHR, or the CMS Web
Interface for groups of 25 or more. It's
important to note data must be submitted
using only one submission mechanism per
performance category for 2018.