How is MIPS Score Calculated ?

Find Out in 10 Simple Steps


First, a little background. The Quality Payment Program under MACRA came into effect on Jan 1st, 2017. All eligible clinicians, are required to participate in this program under one of the two tracks: Merit based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs). All 2019 eligible clinicians (ECs) will earn a performance based payment adjustment for their Medicare payments in 2021. This payment adjustment will be based on Composite Performance Score (MIPS Score) earned by the clinicians on the measures reported under each performance category. Although MIPS is a budget-neutral program, there is $500 million allocated to provide additional incentive to exceptional performers. [Read how MIPS Calculators estimate the payment adjustment]

MIPS eligibility requirements have been modified for the 2019 performance year. New eligible clinician types have been added, Low Volume Threshold (LVT) and eligibility determination periods have been updated. Quality, PI, IA, and Cost categories have all undergone significant changes to the measures, bonus points, measure benchmarks, scoring and submission options.


10 Steps to Calculating MIPS Score

STEP 0: MIPS 2019 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 2019 performance year are:

  • Quality - 45%

  • Promoting Interoperability (PI) - 25%

  • Improvement Activities (IA) - 15%

  • Cost - 15%

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. 

In 2019, the clinicians have the ability to Opt-in for MIPS. There are some special considerations for Small Practices (1-15 eligible clinicians) as well.

OPT-IN OPTION

This new option became available to eligible clinicians/groups in 2019 who meet at least 1 of the 3 Low Volume Threshold (LVT) criteria. Few important points to note are:

  • Opt-in applicable for the entire performance year

  • MIPS payment adjustment would apply

  • Performance will be published on Physician Compare

  • Opt-in guidelines are awaited from CMS

[Read more about MIPS 2019 Opt-In]

FLEXIBILITY FOR SMALL PRACTICES

Practices with ≤ 15 eligible clinicians (ECs), can take advantage of additional flexibility available to Small Practices in 2019:    

a. Small Practice Bonus Modified (6 points added to the Quality category ) - This is a major change from 2018 when 5 points were added to the final MIPS score. Small practices (1-15 ECs) will be awarded 6 points that will be added to the aggregate Quality Numerator. After the bonus is applied, the Quality weighted score will NOT increase by 6 points. E.g. If the totals for numerator and denominator for the Quality category is 40/60, the bonus points will be applied to the numerator before calculating the Quality Percent Score, making it (40+6)/60 = 46/60. To earn this bonus, practices need to submit data for at-least one Quality measure.

b. Hardship Exception for Promoting Interoperability (PI) Category – Small Practices can claim hardship exception in 2019 if they encounter overwhelming circumstances and are unable to utilize a certified EHR to fulfill PI category reporting requirements. The deadline for filing this exception is Dec 31, 2019.

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.

 

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.

In 2019, Claims measures are only available small practices (1-15 eligible clinicians). So ECs in bigger groups cannot use Claims even if they report as individuals.

REPORTING AS INDIVIDUALS

  • The data will need to be reported for every eligible clinician in the group for all applicable MIPS performance categories. (No data submission is required for the Cost category.)

  • MIPS score will be calculated based on individual performance reported, and the payment adjustment will apply to each individual.  

  • Eligible clinicians can submit MIPS data as Individuals via a combination of collection types for the Quality category: EHR (eCQMs), Registry (MIPS-CQMs, QCDR measures), and Medicare Claims measures.

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

  • Small groups of 1-15 eligible clinicians can also report using Claims measures

  • Quality data can be reported via a combination of collection types for the Quality category: EHR (eCQMs), Registry (MIPS-CQMs, QCDR measures), Medicare Claims measures (for small groups only) and CAHPS for MIPS (counts as one quality measure)

  • Groups of 25 or more have an additional option to report through CMS Web Interface. Groups using this collection type cannot combine with any other collection-type except CAHPS for MIPS. To be able to use CMS Web Interface and CAHPS for MIPS provider groups need to register by July 1, 2019.

  • 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 FACILITY-BASED CLINICIANS

Starting with 2019, CMS will identify clinicians and groups eligible for facility-based scoring. The qualifying clinicians and groups may have the option to use facility-based measurement scores for their Quality and Cost performance categories. Clinicians/Groups will still need to submit data for PI and IA performance categories. The best MIPS score out of the two will be used to determine Payment Adjustment.

Facility-based clinicians/groups will still need to submit data for PI and IA performance categories. The best MIPS score out of the two will be used to determine Payment Adjustment.

Facility-based measurement scoring will be used for Quality and Cost performance category scores when:

  • Clinicians/groups are identified as facility-based; and

  • Can be attributed to a facility with a Hospital Value-Based Purchasing (VBP) Program score for the 2019 performance period; and

  • The Hospital VBP score results in a higher score than the MIPS Quality measure data you submit and MIPS Cost measure data we calculate for you


REPORTING AS A MIPS-APM

The MIPS score for MIPS APM participants will be calculated using the APM Scoring Standard. The performance category weights have been made uniform for all the MIPS APMs. That means, the performance category weight distribution stays the same for Medicare Shared Saving Program (MSSP), Next-Gen ACO, and the Other APMs. 

In addition to the MIPS APMs participants, the APM Scoring Standard will also apply to the participants of dual status APMs (Advanced APM and MIPS-APM) who are not deemed to be QP or Partial QP. It will also apply to participants who qualify for Partial QP status and choose to participate under MIPS. The APM Scoring Standard takes precedence for MIPS score calculation for clinicians reporting as a Group/Virtual Group and as a MIPS-APM.  

 

STEP 2: Specialty Measure Sets

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 from the 39 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 will not be penalized for reporting <6 measures as long as they report ALL the measures in that measure-set.

CMS has grouped measures by specialty to make it easier for the providers to find the relevant measures. However, measures outside the specialty set can also be reported if they are relevant.

 

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 2019, 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.

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 118 Improvement Activities available in 2019. 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).

*10 point bonus towards the Promoting Interoperability (PI) category for reporting an eligible Improvement Activity via EHR has been removed for 2019.

STEP 5: Promoting Interoperability (PI) - Exclusions and Exceptions

The Promoting Interoperability (PI) 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 under certain circumstances.

EXCEPTIONS (Applicable at Category Level)

On the basis of provisions in the 21st Century Cures Act and MACRA, CMS will reweight the PI category to 0% and its weight (25%) assigned to the Quality performance category in case of automatic reweighting and reweighting by hardship exception application.

a. Automatic Reweighting 

The PI 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

  • MIPS Eligible PA, NP, CNS, CRNA, PT, OT, Qualified speech-language pathologists, Qualified audiologists, Clinical psychologists, and Registered dietitian or nutrition professionals

b. Reweighting by Hardship Exception Application

Eligible clinicians can submit an application by Dec 31, 2019 to claim the hardship exception and get the PI category reweighted to 0%. Clinician will qualify to file for exception in following situations:

  • MIPS-eligible clinicians in small practices

  • MIPS-eligible clinicians using decertified EHR technology

  • Lack of control over the availability of CEHRT

  • Insufficient Internet connectivity

  • Extreme and uncontrollable circumstances (Natural Disasters, Practice Closure, Severe Financial Distress, or Vendor Issues)

EXCLUSIONS (Applicable at Measure Level)

Eligible clinicians who are not automatically exempted or claim the hardship exemption have to report on all the required measures under the four objectives or claim an exclusion to earn any score in the PI category. These objectives are:

  1. ePrescribing (1 measure + 2 bonus eligible measures)

  2. Health Information Exchange (2 measures)

  3. Provider to Patient Exchange (1 measure) - *No exclusion available*

  4. Public Health and Clinical Data Exchange (Report to any 2 out of 5)

NO EXCLUSION is available for Security Risk Analysis (SRA) and Provider to Patient Exchange. These have to be completed in order to earn a PI score.

STEP 6: Promoting Interoperability Scoring

2015 EDITION CERTIFIED EHR REQUIRED

Not having a 2015 Certified EHR might limit your ability to pick the best 90-days

To submit PI data, eligible clinicians must use a 2015 Edition Certified EHR. The submission will be valid as long as your EHR acquires 2015 Edition Certification by the last day of the chosen 90-day performance period. However, the 2015 edition functionality must be available throughout the performance period.


PI OBJECTIVES AND MEASURES FOR 2019

Clinicians must report on all the required measures (except the bonus measures) across all the objectives or claim an exclusion (when applicable) to earn a score in the PI category. A numerator of 1 is required for each measure being reported as a numerator/denominator to earn a score in the PI category. Each measure has different maximum points assigned which will change when exclusions are claimed due reallocation of points.

Objectives
Measures
Max Points
Reporting
Exclusion
e-Prescribing e-Prescribing
10 pts
Num/Den
Available
Bonus: Query of Prescription Drug Monitoring Program (PDMP)
5 pts
Num/Den
Bonus: Verify Opioid Treatment Agreement
5 pts
Num/Den
Health Information Exchange Support Electronic Referral Loops by Sending Health Information
20 pts
Num/Den
Available
Support Electronic Referral Loops by Receiving and Incorporating Health Information
20 pts
Num/Den
Available
Provider to Patient Exchange Provide Patients Electronic Access to Their Health Information
40 pts
Num/Den
Public Health and Clinical Data Exchange Choose two of the following:
Immunization Registry Reporting
Electronic Case Reporting
Public Health Registry Reporting
Clinical Data Registry Reporting
Syndromic Surveillance Reporting
10 pts
Yes/No
Available
Protect Patient Health Information Security Risk Analysis
0 pts
Yes/No

BONUS POINTS

The new structure for the PI category offers opportunity for 10 bonus points under the e-Prescribing objective.

  • Query of Prescription Drug Monitoring Program (PDMP) - 5 points

  • Verify Opioid Treatment Agreement - 5 points

MAXIMUM POINTS

You can only earn a maximum of 100 points for PI category even though the total points add up to 110 points. If you earn more than 100 points, you will receive the maximum possible score of 25 for the PI category towards your final MIPS score.

NOTE: Following bonus points have been eliminated for 2019:

  • Registry Bonus (5 points) for reporting to one additional Public Health or Clinical Data Registry

  • Improvement Activity Bonus (10 points) for using certified EHR to report certain bonus eligible Improvement Activities

  • 2015 Edition Bonus (10 points) for using a 2015 edition certified EHR to capture the data and report it

REWEIGHTING WHEN EXCLUSIONS CLAIMED

Upon claiming an exclusion, the points for the measure will be assigned to another measure within the PI category keeping the total maximum points the same.

  • e-Prescribing exclusion: When clinician qualifies for exclusion from reporting this measure, the 10 points will be redistributed to both measures under the Health Information Exchange objective equally making their weight 25 points each.

  • Support Electronic Referral Loops by Receiving and Incorporating Health Information exclusion: The weight will be reallocated to the Support Electronic Referral Loops by Sending Health Information measure within the Health Information Exchange objective making it worth 40 points.

  • Support Electronic Referral Loops by Sending Health Information exclusion: Details of reallocation of the measure points if exclusion is claimed for this measure will be specified in 2020 rule-making and will be effective retroactively to 2019.

  • Public Health and Clinical Data Exchange exclusion: Exclusion can be claimed for just one or both the public health /clinical data registries required to be reported to. If exclusion is claimed for just one, then the one being reported will carry all 10 points. If exclusion is claimed for both, the 10 points are allocated to the Provide Patients Electronic Access to Their Health Information measure, making it worth 50 points.

 

STEP 7: Cost Category

The Cost performance category has 15% weight for the 2019 performance year. CMS will calculate the score for the Cost category from the Medicare Administrative Claims data for the entire calendar year 2019. Thus, no data submission is required. The 10 Cost measures that will be considered in 2019 are:

COST MEASURES FOR MIPS 2019

Cost Meaure Measure Type Case Minimum
Medicare Spending Per Beneficiary (MSPB) - 35
Total Per Capita Cost for all attributed beneficiaries (TPCC) - 20
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

Each measure will be scored out of 10 points based on the measure benchmarks. Only the measures for which your organization meets the case-minimums will be scored. [MORE ON COST CATEGORY]

 

STEP 8: Quality Weight, New Terminology, and Measure Selection

Quality category carries the maximum weight towards final MIPS score and requires data to be reported for the full calendar year (Jan 1, 2019 – Dec 31, 2019). Quality category weight has been set to 45%  for 2019 unless you apply for PI hardship exception (see Step 5). In that case, the PI category weight of 25% is assigned to Quality category making the Quality category weight 70%.

COLLECTION TYPES, SUBMISSION TYPES, AND SUBMITTER TYPES

In 2019 the old terminology of Submission Methods and the Reporting Methods has been changed to reflect the submission experience of the eligible clinicians. The new terminology is three-fold  :  

1. COLLECTION TYPES: These are different measure types available to submit

  • eCQMs (EHR measures or electronic Clinical Quality Measures)

  • MIPS CQMs (previously known as Registry measures)

  • QCDR measures

  • Claims measures (available only to small practices of 1-15 eligible clinicians submitting as individuals, groups, or virtual groups)

  • CAHPS for MIPS survey (available only to groups)

  • CMS Web Interface measures (available only to groups of 25 or more)

    *The benchmarks for each collection type will vary even for the same measure. eCQMs need to be calculated using the 2019 specifications provided by CMS from a 2015 Certified EHR. Old CQM versions will not be acceptable.

    * Groups planning to use CMS Web Interface and/or CAHPS for MIPS Survey will need to register between April 1, 2019 and July 1, 2019.

2. SUBMISSION TYPES: The mechanism by which a submitter type submits data to CMS are now known as the Submission Types.

  • Direct: The direct submission type allows users to transmit data through a computer-to-computer interaction (API embedded in the EHR).

  • Log in and Upload: Enables users to upload and submit data in the form and manner specified by CMS with a set of authenticated credentials (EIDM account).

  • Medicare Part B claims

  • CMS Web Interface

3. SUBMITTER TYPES: The entity submitting the data will now be referred to as the Submitter Types

  • Individual MIPS eligible clinician

  • MIPS eligible Group (and virtual group)

  • Third-party Intermediary acting on behalf of clinician or group

SELECTING QUALITY MEASURES

MULTIPLE COLLECTION TYPES ALLOWED: For 2019, you can mix and match all applicable collection types to submit 6 measures, unless your specialty set has less than 6 measures (see step 2). This flexibility doesn’t apply to CMS Web Interface users, who need to submit all 10 specified 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.

Quality measures under MIPS have been sub-categorized into Efficiency, Intermediate Outcome, Outcome, Patient Engagement /Experience, Process and Structure measures. High Priority Measures have been tagged as (P) in the MyMipsScore app.

 

STEP 9A:  Data Requirements for Quality Measures

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. 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.

MyMipsScore automatically selects the best mix of 6 measures from different collection types that yield the highest score for you after taking into account all the criteria discussed in the 10 steps.

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 might yield only 3 points, but Numerator/Denominator of 18/20 could yield 10 points.

Measure Benchmarks: 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.

STEP 9B: Quality Score Calculation: Measure Achievement and Bonus Points

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). Similarly, groups using CMS Web Interface need to submit 10 measures, making the maximum points 100. Whenever 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 collection type (submission method) and the corresponding benchmark determines the points earned for each measure. For 2019 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. The average of these 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. 

High-Priority-Bonus-Points-MyMipsScore.png
  • 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. (Not available for CMS Web Interface in 2019)

  • 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. 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.

*NOTE: 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.

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 eCQM, MIPS-CQMs, QCDR Measures, and CMS Web Interface collection types. 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 2019 Quality category performance as compared to 2018 performance. The improvement score will be calculated at the performance category level, so ECs can select different Quality measures in 2018 and 2019. 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 for 2019

 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. Small Practice Bonus (6 points)

All clinicians who submit data as Individuals, Groups, Virtual Groups, or APM entities, will have 6 points added to their Quality Category (numerator) if they qualify as small practice (have 1-15 eligible clinicians).

h. 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 45 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.

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 + Small Practice Bonus Points if applicable) / Total Applicable Measure Points] x 100 + Improvement Percent

For example: Quality Performance Category Percent Score = [(40 +2+1+6)/60] x100 + 9%

= 81.67% + 9%

 = 90.67%

This will then be multiplied by the Quality category weight to arrive at the Quality category score.

= 90.67% x 45

=40.80

 

STEP 10A:  Final MIPS Score Calculation 

REWEIGHTING

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 (PI), 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 (30 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 (Medicare + Medicaid) 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

FINAL MIPS SCORE - COMPOSITE PERFORMANCE SCORE

Final MIPS Score = IA Weighted Score + PI Weighted score + Quality Weighted Score + Cost Weighted Score + Complex Patient Bonus

Final MIPS Score = IA Weighted Score + PI Weighted score + Quality Weighted Score + Cost Weighted Score + Complex Patient Bonus
 

STEP 10B: MIPS 2019 Payment Adjustment

Based on your 2019 MIPS score, CMS will apply a maximum of +/-  7% payment adjustment to your 2021 Medicare Part B allowed charges. [READ: How MIPS Calculators Work?]

Base Payment Adjustment Range:  +/-  7%

For MIPS Score 0 to 7.5 Points: Full penalty of -7% is applicable. Maximum penalty determined for the performance year applies if the score is at or below ¼th of the Performance Threshold for that year (30 x ¼ = 7.5).

For MIPS Score 7.51 – 29.99 Points: Negative payment adjustment gradually decreasing on a linear sliding scale from -7% to < 0% will apply

For MIPS Score of 30 Points: Payment adjustment of 0% at the Performance Threshold of 30.

For MIPS Score 30.01 – 74.99 Points: Providers will receive the budget-neutral component of positive payment adjustment which is scaled from 0% to 7% to provide maximum adjustment of 7% at MIPS score of 100. A scaling factor (up to a max of 3) will be used to equitably distribute every single cent of the penalties collected.

For MIPS Score 75 – 100 Points: Budget-Neutral + Exceptional Performance Payment Adjustment The providers whose score lie in this range will not only earn the budget-neutral payment adjustment, but will also earn an additional exceptional performance positive payment adjustment. This bonus will be given out from $500 million annual budget starting at +0.5% for MIPS score of 75, up to a max of +10% for a MIPS score of 100. Another scaling factor will be utilized to ensure a fair distribution of the exceptional performance incentives, i.e. more money for a higher score and stay within the annual budget of $500 million.


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.