The Cost category for the Merit-based Incentive Payment System (MIPS) may be one of the most misunderstood categories, according to the Quality Reporting Engagement Group.
The Cost category is proposed to increase by 5 percent each year to eventually be 30 percent of the MIPS composite score by 2022, as mandated under the MACRA law. Practices will not have to submit data for this category as the Centers for Medicare & Medicaid Services (CMS) uses administrative claims data to attribute patients and score, so there is no way to avoid being scored in this measure if you meet the case minimum requirements.
Those requirements include:
- Total per Capita Cost (TPCC) – based on a case minimum of 20 patients and the primary care service volume. CMS scores this measure based on the average cost per attributed patient for all Part A and Part B allowed charges, including charges billed outside of your TIN.
- Medicare Spending per Beneficiary (MSPB) – based on a case minimum of 35 episodes and the service volume during an episode of care surrounding an inpatient hospitalization. CMS looks at how expensive an episode of care for Medicare is – or the average cost per patient for every inpatient hospital admission, including three days prior, during and up to 30 days post discharge of the hospital admission.
CMS scores these two Cost measures by awarding more points the lower your average cost per beneficiary.
If your clinicians or practice do not meet the case minimums, you will not be scored, and you will not receive feedback in the Cost category. You only receive feedback for Cost measures for which you meet the case minimum. If your practice meets the case minimum for one Cost measure but not the other, CMS will use the numbers for the one measure as your score for the Cost category.
In addition, if there are no established benchmarks for data they took from your claims (example: a new measure was implemented one year, so no data is available from the prior year), CMS will only provide feedback if you have met the case minimum. This would apply to the following eight episode-based measures:
- Elective Outpatient PCI
- Knee Arthroplasty
- Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Routine Cataract Removal with IOL Implantation
- Screening/Surveillance Colonoscopy
- Intracranial Hemorrhage or Cerebral Infarction
- Simple Pneumonia with Hospitalization
- STEMI with PCI
If you have questions about the Cost category and how your claims data is reviewed, or any other category of your MIPS performance process, contact firstname.lastname@example.org