It's Easy - Just Follow the Steps
The Merit based Incentive Payment System (MIPS) came into effect on Jan 1st, 2017. Eligible clinicians, who decide to participate in MIPS this year onward, will earn a performance based payment adjustment for their Medicare payments starting in 2019. This payment adjustment will be based on Composite Performance Score (MIPS Score) earned by the clinician on the measures reported. MIPS is designed to be a budget-neutral program, but there is $500 million allocated to provide additional incentive to exceptional performers.
2018 is the second year of MIPS and some things have changed since 2017 performance year. MyMipsScore breaks down this complex process of MIPS Score calculation into 10 simple steps. These steps aim at not only to help you understand how MIPS score is calculated, but also to enable you to calculate this score for your practice, monitor it on a regular basis and help you maximize it.
These steps are arranged in the order of information flow. Choices made in one step influence the options and requirements in the subsequent steps.
STEP 0: MIPS 2018 Performance Category Weights
The MIPS Score, also known as Composite Performance Score (CPS) will be calculated from data reported by practices under the four performance categories to CMS. The category weights for 2018 performance year are:
- Quality - 50%
- Advancing Care Information (ACI) - 25%
- Improvement Activities (IA) - 15%
- Cost - 10%
The sum of weights for all the categories adds up to 100. MIPS score is calculated based on the points earned in each performance category AND the weight for that category.
STEP 1: Reporting as an Individual, as a Group, as a Virtual Group, or as MIPS-APM
An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). Whereas, a group is defined as a set of clinicians (identified by their NPIs) sharing a common TIN, irrespective of specialty or practice site.
REPORTING AS INDIVIDUALS
The data will need to be reported for every eligible clinician in the group for all four MIPS performance categories
MIPS score will be calculated based on individual performance reported, and the payment adjustment will be calculated accordingly
MIPS data can be submitted via EHR, Qualified Registry (QR), Clinical Data Registry (QCDR) or Medicare Claims
REPORTING AS A GROUP
Data will need to be aggregated at the group-level for each of the MIPS categories and then reported
All the eligible clinicians in the group will get one MIPS score based on the group’s performance
Data can be reported via EHR, Qualified Registry (QR), Clinical Data Registry (QCDR), and CAHPS for MIPS (for one quality measure)
Groups of 25 or more have an additional option to report through CMS Web Interface which requires registration by June 30, 2018.
Groups of 16 or more may have to report on an additional quality measure - 30 Day All-Cause Hospital Readmission Measure. However, it would be calculated by CMS from the Administrative Claims data pertaining to the group, and would not need to be reported.
Rules and options available for groups will also be applicable to Virtual Groups (except the low volume threshold)
REPORTING AS A MIPS-APM
The APM scoring standard has been standardized for 2018. Unlike the APM scoring standard in 2017 in which the performance category weights and requirements were different for Medicare Shared Saving Program (MSSP) tracks and Next-Gen ACO tracks, but different for all the other APMs, the performance category distribution is same for all the MIPS-APMs in 2018:
- Quality - 50%
- Advancing Care Information (ACI) - 30%
- Improvement Activities (IA) - 20%
- Cost - 0%
The APM scoring standard will also apply to the APM participants with the dual status of Advanced-APM and MIPS-APM, who don’t qualify for the QP status or Partial QP status. It will also apply to participants who qualify for Partial QP status and choose to participate under MIPS.
The APM scoring standard takes precedence when clinicians reporting as a Group or Virtual Group are also participating in a MIPS-APM.
FLEXIBILITY FOR SMALL PRACTICES
If reporting as individuals or as a group, and your practice TIN has 15 or less eligible clinicians, you might be able to take advantage of additional flexibility available to Small Practices in 2018:
The definition of Small Practice has been modified in Final Rule 2018 to refer to the practices consisting of 1-15 eligible clinicians.
a. Small Practice Bonus Points (5 points added to final MIPS score) - Small practices (practices consisting of 1-15 eligible clinicians) will be awarded 5 additional points towards the final MIPS score E.g. For a small practice, a MIPS score of 65 will become 70 (65+5). This bonus will be awarded only if the MIPS eligible clinician submits data for at least 1 performance category for the performance year 2018 (other than the Cost category for which no submission is required).
b. Hardship Exception for ACI – Small Practices can claim hardship exception in 2018 if they encounter overwhelming circumstances and are unable to utilize a certified EHR to fulfill ACI category reporting requirements. The deadline for filing this exception is Dec 31, 2018.
c. Data Completeness Requirement Not Met - Under Quality category, a Small Practice would earn 3 points for the measure that fails data completeness of 60%, whereas practices with 16 or more eligible clinicians will earn only 1 point.
d. Double Weight for Improvement Activities – Small Practices are awarded double the points for both the medium-weight and high-weight activities, thus reducing the number of activities that they need to report. This flexibility for IA category remains the same as in 2017 performance year.
STEP 2: Specialty
There are no specific MIPS requirements based on the specialty of an eligible clinician. However, the number of required measures in the Quality category may vary based on the specialty. Most providers will be required to report 6 Quality measures. Providers can either pick the 6 measures for the specialty-specific measure sets defined by CMS, or pick any 6 applicable measures. In case a specialty-specific measure set has less than 6 measures, providers can report on only those measures without being penalized.
CMS has grouped measures by specialty to make it easier for the clinicians to find the relevant measures. However, measures outside the specialty set can be reported too if they are relevant to the reporting entity.
STEP 3: Improvement Activities (IA) Special Considerations
The Improvement Activities performance category rewards clinicians for delivering care that emphasizes care coordination, patient engagement, and patient safety. For 2018, data for a minimum of 90 continuous days will need to be reported for the IA category.
You may be eligible to receive special scoring considerations under this category if your practice meets certain criteria:
- Your practice is in a rural area or a health professional shortage area (HPSA)
- Yours is a Small Practice (has 15 or fewer eligible clinicians)
- You are a non-patient-facing clinician
If any of the above situations apply to you, you will be awarded double the points (20 points for a medium weight activity, and 40 points for a high weight activity) for all the Improvement Activities you chose to report, enabling you to achieve the maximum score with lesser effort.
If 50% of the practice sites within a TIN are certified as Patient Centered Medical Home (PCMH), the TIN will earn full credit for the IA category.
STEP 4: Improvement Activities Scoring
You have to attest that you completed one or more out of 112 Improvement Activities available in 2018 (up from 93 available in 2017). You can earn a maximum of 40 points for this category (carries 15% weight towards the final MIPS score). Improvement Activities are divided into medium-weight and high-weight activities. High-weight activities carry twice the weight of the medium-weight activities, and therefore count twice as much towards the final MIPS score (marked with H icon in MyMipsScore).
A few Improvement Activities are reportable via EHR and will help you earn 10 bonus points towards the ACI category (marked with an E icon in MyMipsScore).
STEP 5: Advancing Care Information (ACI) - Exclusions and Exceptions
The ACI performance category assesses the meaningful use of certified EHR technology under the Quality Payment Program(QPP). Certain exclusions and exceptions are available for MIPS eligible clinicians if they are faced with certain circumstances. Let us understand how they are defined in 2018.
Eligible clinicians have to report on the ACI, but they can claim exclusion to report data for certain measures if they meet the criteria defined for those measures. For instance, exclusion can be claimed for the E-Prescribing measure, by a MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period. Claiming the exclusion allows the eligible clinicians to complete the ACI base requirements and earn an ACI score. Claiming an exclusion does NOT reweight the ACI category to 0%. Additionally, exclusion CANNOT be claimed for Security Risk Analysis and Providing Patient Access. These have to be completed in order to fulfill base requirements and earn a ACI score.
On the basis of provisions in the 21st Century Cures Act and MACRA, CMS will reweight the ACI category to 0% and its weight (25%) assigned to the Quality performance category in the following situations:
a. Automatic Reweighting: The ACI category will automatically be reweighted to 0% without submitting any application for:
- Hospital-based MIPS eligible clinicians
- Non-Patient-Facing clinicians or groups with >75% NPF clinicians
- Ambulatory Surgical Center (ASC) based MIPS eligible clinicians (will also apply in 2017)
- MIPS eligible Physician Assistants, Nurse Practitioners, Clinical Nurse Specialist, and Certified Registered Nurse Anesthetists
b. Reweighting by Hardship Exception Application: Eligible clinicians can submit an application by Dec 31, 2018 to claim the hardship exception and get the ACI category reweighted to 0%. Clinician will qualify to file for exception in following situations:
- Clinicians in a Small Practice (1-15 eligible clinicians) facing overwhelming barriers to adopting a certified EHR (new hardship exception introduced in 2018)
- Clinicians whose EHR got decertified during the performance year (will also apply in 2017)
- MIPS Eligible Clinicians facing significant hardship defined as:
- Have insufficient internet connectivity
- Extreme and uncontrollable circumstances (e.g. Natural Disasters)
- Lack of control over the availability of Certified EHR technology
STEP 6: ACI Measure Set Selection and Scoring
ACI MEASURE SET SELECTION
The Advancing Care Information category requires eligible clinicians to report a group of objectives and measures for MIPS. These are called Measure Sets which are based on the EHR edition being used. The data for the selected measure set needs to be reported for a minimum of 90 continuous days (similar to 2017). In 2018, there are two measure set options available for reporting (just like 2017). Clinicians can use either 2014 or 2015 certified EHR editions during performance year 2018 for reporting ACI performance.
- Option 1 - Advancing Care Information Objectives and Measures You need to have a 2015 Edition, or a combination of 2014 and 2015 EHR editions to choose this option.
- Option 2 - 2018 Advancing Care Information Transition Objectives and Measures This is the only option if you have a 2014 edition EHR.
The same amount of points can be earned using either option. Option 1 has some additional options available under the Public Health and Clinical Data Registry Reporting. But to even out the maximum number of points for both the options, two measures in Option-2 have been assigned twice the maximum points. However, those picking Option 1 have an opportunity to earn an additional bonus of 10 points which is available for exclusively using the 2015 edition EHR for capturing and reporting ACI performance.
There is no change in the scoring policy for the ACI category from 2017 apart from hardship exception for Small Practices, and the 10 bonus points available for utilizing 2015 edition certified EHR. The ACI score is divided into three parts:
a. Base Points (Max 50)
All the measures categorized as Base Measures need to be reported in order to receive any credit for the ACI category. Full 50 points can be earned for answering YES for the yes/no measures, and entering a Numerator and Denominator for the rest. The performance on the measures doesn’t impact the scoring for base points.
b. Performance Points (Max 90)
The performance points are awarded based on the performance on the measures in your selected measure set. It is noteworthy that some of the measures included in the Base Points also count towards the Performance Points. Additionally, 10 points that were available for reporting data to an Immunization Registry have now been extended to all the Public Health and Clinical Data Registries. 10 Performance Points can be earned for reporting data to any such registry that is relevant to the practice.
c. Bonus Points (Max 25)
There are three types of bonus points available under ACI in 2018:
- Registry Bonus (5 points) – Reporting to at least one additional Public Health or Clinical Data Registry. This has to be a different Registry than the one you reported to under “Performance Points”. Same Registry can’t count twice.
- Improvement Activity Bonus (10 points) – For using certified EHR to report certain bonus eligible Improvement Activities (see Step 4)
- 2015 Edition Bonus (10 points) – For using a 2015 edition certified EHR to capture the data and report it for the ACI performance category (available only if you use Option 1)
You can only earn a maximum of 100 points for ACI category even though the total points add up to 165 points (50 + 90+ 25 = 165). If you earn more than 100 points, you will receive the maximum possible score of 25 for the ACI category towards your final MIPS score.
STEP 7: Cost Category
The Cost performance category has 10% weightage for the 2018 performance year. CMS will calculate the score for the Cost category from the Medicare Administrative Claims data for the entire calendar year 2018. Thus, no data submission is required. The score will be calculated only if your organization meets the case minimum requirement for the two measures that will be considered in 2018, which are:
- Medicare Spending Per Beneficiary (MSPB) – Case minimum of 35
- Total Per Capita Cost for all attributed beneficiaries - Case minimum of 20
If only one measure can be scored, the performance on that measure will determine the Cost category score.
COST IMPROVEMENT SCORING
Following the Bipartisan Budget Act of 2018 (HR 1892) enacted on Feb 9, 2018, the performance improvement for Cost category will not be considered for 2018 MIPS score calculations.
STEP 8: Quality Submission Methods and Measure Selection
Quality category carries the maximum weight towards final MIPS score. For 2018, this has been set to 50% unless you apply for ACI hardship exception [see Step 5]. In that case, the ACI category weight of 25% is assigned to Quality category making the Quality category weight 75%. Additionally, in 2018, Quality data will need to be reported for the full calendar year (Jan 1, 2018 – Dec 31, 2018).
SUBMISSION METHOD FOR QUALITY CATEGORY
The MIPS Quality category scoring utilizes a decile based benchmarking system. Under this system, each quality measure is assigned a benchmark for each submission method applicable. Hence the score for a measure could be little or very different for EHR and Registry submission methods for the same performance rate.
In 2018, only one submission method can be chosen to submit all the quality data just like in 2017. The submission method chosen not only impacts the score, it can also define the minimum number of quality measures required to be reported. Most of the providers will need to report 6 quality measures (or the Specialty Set as described in Step 2).
If you pick CMS Web Interface submission method (only available to groups of 25 or more), you need to report all the 14 measures included in the CMS Web Interface (includes the two-part Diabetes measure).
SELECTING QUALITY MEASURES
Quality measures under MIPS have been sub-categorized into Efficiency, Intermediate Outcome, Outcome, Patient Engagement/Experience, Process and Structure measures.
Some of these measures have been tagged as High Priority Measures (P), while some have been tagged as bonus eligible for CEHRT/end-to-end reporting (E).
Unless you select the CMS Web Interface option or your specialty set has less than 6 measures (see step 2), you must report on a minimum of 6 measures. Out of these 6 measures, one measure must be an Outcome Measure or a High Priority measure in lieu of it, in case no outcome measure applicable to your practice. You will receive bonus points for selecting additional high priority or outcome measures.
STEP 9: Data Requirements for Quality Measures and Quality Score Calculation
There are a couple of things you need to know before you start entering your data for Quality category:
Data Completeness Requirements: Minimum 60% data completeness is required to achieve max points for each measure (except for CMS web interface and CAHPS for MIPS submission methods). That means you must report that at least 60% of your total patients who meet the measure's denominator criteria, regardless of payer (Medicare and Non-Medicare) except for Claims for which only Medicare Part B beneficiaries count. Less than 60% completeness will yield only 1 point (Small Practices will get 3 points) for all submission methods except CMS Web Interface. For CMS Web Interface, less than required data completeness will yield ZERO points for that measure.
Case Minimum of 20: For all the Quality measures, you must at least report 20 cases, i.e., the denominator must be 20 or more for you to earn more than 3 points for that measure. For instance, a Numerator/Denominator of 18/18 will yield only 3 points, but Numerator/Denominator of 18/20 could yield 10 points. For CMS Web Interface, if you meet the Data Completeness Criteria, but don’t meet the Case minimum, the measure will not be scored (i.e., will not be counted towards max points).
*Important Note* Score for two different measures can be very different even with an identical performance rate based on the benchmark and bonuses available for the measures. We encourage you to select as many measures as you can and enter data for all of the measures. MyMipsScore automatically selects the 6 measures that yield the highest score for you after taking into account all the criteria discussed in the 10 steps.
QUALITY SCORE CALCULATION
a. Determine the maximum points. If you are reporting a Specialty Measure Set that has less than 6 measures, your max points would be less than 60 (no. of measures x 10). Although there are a minimum 14 reportable measures for CMS Web Interface submission mechanism, the max score is NOT 140, but 110 as only 11 measures have a benchmark. The 3 measures that don’t have a benchmark will not be scored if you report all the measures, but you would be penalized for not reporting all the measures. In case the All-Cause Hospital Readmission Measure is applicable to your group, your max points will go up by 10 points. For all other providers, the maximum points will be 60 (based on 6 measures).
b. Calculate Achievement Points: Eligible clinicians can earn maximum of 10 points for each of the six measures. The submission method and the corresponding benchmark determines the points earned for each measure. For 2018 performance year, maximum points for six of the topped-out measures have been capped at 7 points (not 10 points even after meeting all performance criteria).
c. CAHPS for MIPS Achievement Points: Groups and Virtual Groups can report CAHPs for MIPS survey as one quality measure towards the required 6 measures. The survey comprises of 10 Summary Survey Measures (SSMs) where each SSM has its own benchmark. Out of these 10, only 8 SSMs will be scored in 2018. The average of these 8 SSMs will determine the performance rate for the CAHPS for MIPS. In addition to the achievement points, CAHPS for MIPS will also earn 2 bonus points as it is classified as a Patient Experience Measure.
d. Calculate High Priority Bonus Points: The following type of measures are collectively classified as high priority measures and bonus points can be earned for reporting these measures. These measures are labelled as O, P, X in MyMipsScore.
- 2 bonus points for each additional Outcome Measure (O) - The first outcome measure selected does not qualify.
- 1 bonus point for each additional High Priority Measure (P) - reported in addition to the one reported in lieu of the one required outcome measure.
- 2 bonus points for each Patient Experience Measure (X)
The OPX bonus points are capped at 10% of the maximum achievement points. If Maximum Points is 60, you can only earn 6 bonus points.
To earn High Priority bonus points for a measure, the data must meet the 60% data completeness, 20 case minimum requirement, and have numerator ≥1.
You can submit more than the required number of measures and earn bonus points related to these additional measures (even though the achievement points are not included) if the above-mentioned bonus criteria are satisfied.
e. Calculate CEHRT Bonus Points: Additional bonus points can be earned for reporting the measures in a manner that meets end-to-end electronic reporting criteria. This bonus is available for EHR, QCDR, Qualified Registries, and CMS Web Interface submission methods. End-to-end means no manual intervention in any step from the point of data creation to submission to CMS. Hence, it is not applicable for Claims submission method. CEHRT bonus points are also capped at 10% of the maximum achievement points.
f. Quality Improvement Scoring will be calculated for the eligible clinicians and groups that show improvement in 2018 Quality category performance as compared to 2017 performance. The improvement score will be calculated at the performance category level, so ECs can select different Quality measures in 2017 and 2018. Up to 10 percentage points could be earned for showing an improved performance in the Quality category. The improvement score will be calculated as long as there is a previous year performance to be compared. 30% of performance category score will be considered as the base. Improvement will be calculated from there. Read more on Quality Improvement Scoring
Improvement Percent Score = (increase in quality performance category achievement percent score from prior performance period to current performance period / prior performance period quality performance category achievement percent score) x 10
g. Quality Performance Category Score: You cannot earn more than 100% of the maximum points for a performance category. If the maximum points for you are 60 and you earn a total of 66 points including bonuses, your score will be capped at 60 points. You will get full credit for the Quality category (Quality category score of 50 points) towards calculation of your final MIPS Score.
Note: If you are a group of 16 or more providers, CMS will calculate your performance in the All Cause Hospital Readmission Measure from the Administrative Claims data. It will be scored only if your group meets the minimum case requirement of 200 for this measure, and will be added to your Quality score by CMS to determine the final MIPS score.
From 2018, the Quality category points will be expressed as a percent which will be calculated as: Quality Performance Category Percent Score = [(Total Achievement Points + Total OPX Bonus Points + Total CEHRT Bonus Points) / Total Applicable Measure Points] x 100 + Improvement Percent
For example: Quality Performance Category Percent Score = [(40 +3+6)/60] x100 + 9%
= 81.67% + 9%
This will then be multiplied by the Quality category weight to arrive at the Quality category score.
STEP 10: Final MIPS Score Calculation
In case a performance category cannot be scored due to lack of applicable measures (Quality), inability to meet case minimum requirements or unavailability of a benchmark (Cost), lack of control over EHR, or lack of patient facing interactions (ACI), or extreme circumstances (IA), the weight will be redistributed to other performance categories. The MIPS eligible clinicians /groups/virtual groups must submit data for at least 2 performance categories in order to get a MIPS score. As long as 2 performance categories can be scored, the weight for other performance categories unable to be scored would be allocated to the two performance categories being scored.
In the rare occurrence of inability to submit the data for even 2 performance categories (natural disasters), the affected clinicians will be assigned a score equal to the performance threshold (15 points) to prevent any negative payment adjustment.
COMPLEX PATIENT BONUS POINTS (Max 5 points)
Up to 5 bonus points can be earned for the treatment of complex patients. This would be determined based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dually eligible patients treated. You must submit data for at least 1 performance category to earn this bonus.
Complex Patient Bonus Points will be calculated as:
- For individuals and groups: (Average HCC risk score + Dual Eligible Ratio) x 5
- For Virtual Groups: (Weighted Average HCC risk score of each TIN + Dual Eligible Ratio) x 5
According to the CMS estimates, Complex Patient Bonus will range from 2.52 to 3.72 for most MIPS eligible clinicians.
SMALL PRACTICE BONUS OF 5 POINTS
All clinicians who submit data as Individuals, Groups, Virtual Groups, or APM entities, will have 5 points added to their MIPS score if they qualify as small practice (have 1-15 eligible clinicians).
FINAL MIPS SCORE - COMPOSITE PERFORMANCE SCORE
Final MIPS Score = IA Weighted Score + ACI Weighted score + Quality Weighted Score + Cost Weighted Score + Complex Patient Bonus + Small Practice Bonus
Make MIPS easy for your practice. Use MyMipsScore.
Keeping track of submission methods, measure benchmarks, topped-out measures, case minimums, and bonus requirements in addition to care delivery can be simple with MyMipsScore. Monitor your MIPS score regularly so you can make timely adjustments and maximize your payment adjustments.