Background: Medicare is an official part of the U.S. Department of Health & Human Services. The Centers for Medicare & Medicaid Services (CMS) operates MIPS. The Quality Payment Program (QPP) is under the authority of the CMS. Obamacare emphasizes the Merit-based Incentive Payment System (MIPS) for billing. The amount of reimbursement available comes from the final MIPS Composite Performance Score.

Eligibility: Physicians meet eligibility for MIPS by filing data in 2020. Medical groups can receive payment adjustments from Medicare starting in 2022. Low Volume Threshold (LVT) clinics & institutions that fail to register with MIPS can lose up to 9% in penalty billing. The current LVT standard for MIPS eligibility is for both medical institutions and physicians. They must bill less than $90,000 in annual Part B reimbursement. This includes all totals from Medicare & Medicaid services through PFS.

MIPS Score

Image: Greenway Health

How the MIPS Composite Score is Calculated

The CMS has set four main categories for calculation. These prorate according to a set algorithmic formula. The final result of the MIPS Composite Performance Score is most important. This depends on the review of model submissions. The CMS committee reviews your sets of clinical data. Data sets register with the CMS office to receive MIPS scores from Medicare. The CMS establishes category scoring as a billing system managed by the QPP.

The four main categories used to calculate the MIPS Composite Performance Score are:

  • Quality
  • Improvement Activities
  • Promoting Interoperability
  • Cost

The main recommendation is to maximize the quality of the medical data samples. You can submit a statistical number of data sets that is higher than the smallest value required by the CMS. This ensures that only the top-rated results get classified by the review staff.  The CMS regulates the calculation of the final MIPS Composite Score by percentages.

MIPS Performance Score

Image: Impact Advisors

The MIPS Composite Scoring System for Quality

Most small practices qualify for MIPS under the LVT criteria. There are three main options for data submission to the CMS for score calculation:

  • Individual
  • Group
  • Facility-based

Data sets reported from individuals establish the physician as MIPS compliant. CMS requirements are independent of medical facilities. The CMS requires a single National Provider Identifier (NPI). This key links to a single Tax Identification Number (TIN). The rule is only for the standard categorization.

The CMS has different data submission standards and requirements for groups. The law requires grouping of physicians numbering less than 15, however there are options for groups of 16+/25+ physicians. These laws need quality measures for Medicare access. The collection types for the quality category weight are:

  • EHR (eCQMs)
  • Registry (MIPS-CQMs, QCDR measures)
  • Medicare Claims measures
  • CAHPS for MIPS

Physicians submit data sets for MIPS under the facility-based criteria. They can use attribution from a Hospital Value-Based Purchasing (VBP) score in 2020. Facilities that use this standard will receive a higher quality mark. This calculates under the MIPS Composite Score rating system under LVT standards.

Note: The only other option for physicians with QPP is to report data in the APM system.  

MIPS Composite Scoring for Improvement Activities (IA)

There are three Improvement Activities (IA) that need special considerations. These apply in MIPS scoring ratings. The CMS rewards rural practices in a health professional shortage area. Bonuses are also for small groups of less than 15 physicians. Non-patient facing doctors or specialists can qualify

There are over 100 different Improvement Activities (IA) recognized under this MIPS category. Medical facilities and physicians must register their activity to qualify.  Under each category, results are classified for a period of 90 days.

MIPS Composite Scoring for Promoting Interoperability (PI)

The Promoting Interoperability (PI) standards are set by the QPP. They govern MIPS Composite Score calculation. These promote the institutional use of electronic health records (EHR). Physicians, clinics, & other medical institutions receive higher ratings for compliance. This is for adopting PI-approved EHR software systems.

Note: Groups that do not use electronic reporting will receive a zero rating.

The five main categories for recognized for Promoting Interoperability (PI) are:

  • e-Prescribing: 10 pts
  • Health Information Exchange: 20 pts
  • Provider to Patient Exchange: 40 pts
  • Public Health and Clinical Data Exchange: 10 pts
  • Protect Patient Health Information: Yes/No [0 pts]

Healthcare groups document their standards of adoption for each area. This rule is for MIPS compliance and rank with a higher MIPS Composite Score. Five extra bonus points for this category are available. High priority measures relate to the Query of Prescription Drug Monitoring Program (PDMP). This will help professional practice.  

The MIPS Composite Scoring System for Cost

The cost measures category is a new replacement in MIPS calculation. This is an update from previous VBM standards. The cost rule depicts the total cost of care during a hospital stay. It calculates for particular procedures. The most important categories are for physicians and clinics. They must submit data to MIPS for performance scoring:

  • Medicare Spending Per Beneficiary – Clinical (MSPB-C)
  • Total Per Capita Cost (TPCC) – Attributed Beneficiaries

The MSPB-C classification requires the submission of 35 data sets. These are for background case information. Mail them to the CMS. The TPCC standard only requires data from 20 examples. These data sets calculate the cost value for performance thresholds. Use the MIPS Score final rating with statistical averages. These apply for each Medicare payment category.

Other specializations receive favored quality and cost bonuses under Medicare billing.

MIPS Composite Score

Image: Survey Vitals

Calculating the MIPS Composite Performance Score

The final MIPS Performance Categories rating calculates the number of data sets. These submit to the CMS.  If there are six data sets submitted for the group, facility, or individual, the max score is 60. If ten datasets submit, the max score is 100. The All-Cause Hospital Readmission Measure can add a bonus of 10 points to the score.

The formula for the quality category calculation  is:

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

It is easy to calculate the final MIPS Score. The values from the quality improvement, cost, interoperability, &  IA are all weighted. These calculate together by a composite formula:

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

A score of 45 qualifies for MIPS standards under medium weight verification. These rules apply for any institution, group, or individual. Bonus points earned for a MIPS category are dependent on CMS review via the QPP laws for bonus points.

Scores in the 45 to 85 range will receive up to 9% billing change. This ranks under MIPS scoring following the year 2019. The ranking of MIPS quality determinants is Medicare billing now. For cost-adjusted payment to small & independent healthcare groups, register for MIPS under QPP.

Exceptional performers live in the 85 to 100 range of MIPS Composite Score ratings. You can then receive bonus payments from Medicare. Make sure to pay close attention to your final MIPS performance rates. These guide the future professional verification of institutions, groups, & private practice. It is also now possible for virtual groups to file for MIPS Composite Score ratings.

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