MIPS 2019 :The Cost Category Balancing Act

Evaluating the cost of care alongside the quality of care is not a new concept. It was an element of previous Quality reporting programs like PQRS. With every year of the MIPS, CMS is ramping up the efforts to strike the delicate balance between Cost and Quality of care. In 2017, the transition year to MIPS, the Cost measures were evaluated, not scored. In 2018, clinicians were assessed on only two measures (MSPB + TPCC). For 2019, CMS is ready with 10 measures along with higher weight for Cost category (15%).

This blog will provide you an overview of the 10 Cost measures and how Cost category score will be calculated for 2019 MIPS performance year.


Cost Category Weight - 15%

The Cost performance category weight for 2019 Performance Year is proposed to be 15% (up from 10% in 2018). Thanks to the Bipartisan Budget Act, it will not be increased to 30% for 2019 as was proposed in 2018. Rather, the redistribution of weight between Cost and Quality categories will continue gradually till both Cost and Quality categories have 30%.

MIPS Year 1
MIPS Year 2
MIPS Year 3

Cost Reporting

No submission is required for the Cost Performance Category. CMS will calculate performance on Cost measures from the Medicare Administrative Claims for the entire calendar year (Jan 1, 2019 to Dec 31, 2019).


Performance Category
Collection Type for
Collection Type for
Submission Type
No data submission required

Cost Measures

Cost category performance will be scored on 10 measures for 2019. In addition to the two measures from 2018 (Total Per Capita Cost and MSPB), 8 new episode-based measures have been added. The 8 episode-based measures have been subdivided into Procedural Episode Measures and the Acute Inpatient Medical Condition Episode Measures. Only the Cost measures that meet the attribution criteria and the case minimums will be scored. Following case minimums and the attribution criteria are set in order to be able to score these measures reliably.


Cost Measures
Case Minimum
Attribution of Medicare Beneficiaries to Clinicians
Total Per Capita Cost Measure
Majority of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
Medicare Spending Per Beneficiary (MSPB)
Majority of Part B services billed during the index admission to determine attribution for the MSPB measure
Procedural Episode Measures (5)
Episodes attributed to each MIPS eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes
Acute Inpatient Medical Condition Episode Measures (3)
Episodes attributed to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization

The Episode-based measures are developed to inform the attributed clinicians about the cost of the care they deliver. The cost for only the items and services that are related to an episode of care for a clinical condition or procedure are accounted using Medicare Parts A and B fee-for-service claims data. These costs are based on Episode groups which:

  • Represent a clinically cohesive set of medical services rendered to treat a given medical condition

  • Aggregate all items and services provided for a defined patient cohort to assess the total cost of care.

  • Are defined around treatment for a condition (acute or chronic) or performance of a procedure.

Items and services in the episode group comprise of treatment services, diagnostic services, and ancillary items and services directly related to treatment (such as anesthesia for a surgical procedure). Following 8 measures will be applicable for 2019 MIPS performance year.


Meaure Topic Measure Type
Elective Outpatient Percutaneous Coronary Intervention (PCI) Procedural
Knee Arthroplasty Procedural
Revascularization for Lower Extremity Chronic Critical Limb Ischemia Procedural
Routine Cataract Removal with Intraocular Lens (IOL) Implantation Procedural
Screening/Surveillance Colonoscopy Procedural
Intracranial Hemorrhage or Cerebral Infarction Acute inpatient medical condition
Simple Pneumonia with Hospitalization Acute inpatient medical condition
ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) Acute inpatient medical condition

Cost Score Calculation

The score for the Cost category for 2019 will be calculated similar to 2018. Each applicable measure will be assigned a score between 1-10 points based on the measure performance and benchmarks.

(Cost Achievement Points/Total Available Points)100 = Cost Performance Category Percent Score

Cost Category Score = Cost Percent Score x  15 (Cost category weight)

This percent score cannot not exceed 100%. The percent score will then be multiplied with the Cost category weight to calculate the Cost performance category score.

COST MEASURE BENCHMARKS: The Cost Measure benchmarks will be based on the data of the same performance year, i.e., benchmarks for 2019 will be based on 2019 data. If a benchmark cannot be created for a measure, that measure will not be scored.

CASE MINIMUM REQUIREMENTS: If a Cost measure does not meet the case-minimum requirement, that measure will not be scored.  

IMPROVEMENT SCORING NOT APPLICABLE: The Bipartisan Budget Act of 2018 delayed consideration of improvement in Cost until the 2024 MIPS payment year (based on the 2022 performance year data).  

REWEIGHTING TO QUALITY CATEGORY: If no Cost measures can be attributed to an eligible clinician, or they do not meet the case minimum requirement for not even a single measure, the weight for the Cost category will be redistributed to the Quality performance category, making it 60%.

This concludes the summary of the MIPS 2019 final rule as it pertains to the Cost performance category. We will focus on changes for the Promoting Interoperability category in the next blog. The entire PI category has been completely restructured including the required measures, reporting requirements and bonus points. Stay tuned to understand all the changes and how they can impact your MIPS score.

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