Please reload

Recent Posts

Before the Ransomware Damage is Done

November 24, 2019

Please reload

Featured Posts

MIPS Cost Category: OLD is the new NEW


Recently, CMS finalized the Quality Payment Program Rule for the performance year 2018. One of the key takeaways is that the cost performance category would have a 10% weightage in calculation of the final MIPS score in 2018. Here are the seven things you need to know to prepare for the Cost category for 2018:


1. OLD is the new NEW

Cost was finalized to have a 10% weightage for the 2018 performance year in the just released Quality Payment Program final rule. However, CMS had proposed to reduce Cost to 0% in the 2018 proposal which was submitted for public comment earlier this year. After reviewing the comments, they decided to NOT finalize the proposed change in this final rule. As the Cost category will need to have 30% weightage by the 2019 performance year, CMS believes that keeping it at 10% for 2018 would allow for a smoother transition in 2019. The Cost performance category reporting period will be for the full year in 2018.


2. Cost category score will be calculated from the Medicare administrative claims

Therefore, there is no additional data submission required for performance year 2018. It’s important to note that although CMS will be calculating the Cost score for 2017, the weightage of the cost performance category for 2017 is 0%. Therefore, it will not impact the 2017 MIPS score.


3. Episode based measures will be included for 2017 performance year

Cost performance category score in 2017 will be based on 12 measures – the 10 episode-based measures, the MSPB, and the total per capita cost for all attributed beneficiaries. Whereas, the Cost performance category score for 2018 will be calculated based on just two measures:

  • Medicare Spending Per Beneficiary (MSPB)

  • Total Per Capita Cost for all attributed beneficiaries

The 10 episode-based measures are being evaluated and thus will not be included in 2018.


4. Improvement scoring will apply to Cost category as well

Beginning 2018, the Improvement Scoring will be available for Cost performance category (in addition to the Quality category). The cost improvement score will be calculated by comparing 2018 performance against the 2017 performance and will be reflected in the cost performance category percent score and the 2018 MIPS score.


5. Cost performance category will have its own benchmarks

Similar to the calculation of Quality performance category score, the Cost score would be calculated by comparing performance against benchmarks and the points will be assigned on a decile system. However, there are few differences as compared to the Quality score calculation:

  • The Cost benchmarks will be based on the performance for the same year unlike the Quality benchmarks that are based on prior years’ performance

  • There is no minimum number of measures required. The score will be calculated when the organization meets the case minimum requirement for the two measures, which are:

    • Medicare Spending Per Beneficiary (MSPB) – 35

    • Total Per Capita Cost for all attributed beneficiaries – 20


6. Only Two Cost Measures Applicable in 2018

Here is an overview of the two measures that will be included for 2018. In the follow up blogs, we will drill down into further details of each of these measures.


I. Medicare Spending Per Beneficiary (MSPB)

  • The numerator for a TIN’s specialty-adjusted MSPB Measure is the TIN’s average MSPB amount, which is defined as the sum of standardized, risk-adjusted spending across all of a TIN’s eligible episodes divided by the number of episodes for that TIN. This ratio is multiplied by the national average standardized episode cost. An MSPB episode includes all Medicare Part A and Part B claims with a start date falling between 3 days prior to an Inpatient Prospective Payment System (IPPS) hospital admission (also known as the “index admission” for the episode) and 30 days after hospital discharge.

  • Has been used in the Value Modifier since 2016

II. Total Per Capita Cost For All Attributed Beneficiaries

  • The outcome for this measure is the sum of Medicare Part A and Part B costs for each beneficiary. Costs are payment standardized, annualized, risk adjusted, and specialty adjusted.

  • Has been used in Value Modifier since the 2015 payment adjustment period

  • In the 2017 Quality Payment Program final rule, CMS added the transitional care management (CPT codes 99495 and 99496) codes and a chronic care management code (CPT code 99490) to the list of primary care services that had been used to determine attribution for the total per capita cost measure. In the CY 2017 Physician Fee Schedule, CMS changed the payment status for two existing CPT codes (CPT codes 99487 and 99489) that could be used to describe care management from B (bundled) to A (active) thus allowing these services to be paid under the Physician Fee Schedule. CMS considered the services described by these codes substantially similar to those described by the chronic care management. Therefore, CMS added CPT codes 99487 and 99489 to the list of primary care services used to attribute patients under the total per capita cost measure for 2018


7. Getting ready for the Cost Measures in 2018

The calculation of the two Cost measures requires data that is not easily available to most practices. This combined with the same year benchmark methodology makes it difficult to plan ahead. However, there are few things you can do to get ready:

  • Review your prior year QRURs to understand your historical performance

  • Request an informal review of your QRUR for this year with CMS by Dec 1, 2017 if you disagree with the performance as documented.

  • Analyze your 2017 cost performance category score as soon as it becomes available. As discussed above, the score would be used as the basis for calculating improvement scoring for 2018 cost category performance score.


This article was originally published on MyMipsScore.

Share on Facebook
Share on Twitter
Please reload

Follow Us