The Medicare Access and CHIP Reauthorization Act (MACRA) implements two compensation pathways for physicians receiving payment under Medicare Part B. If you do not know what MACRA is, your practice will most likely be losing 4 percent of that reimbursement in 2019.
One of MACRA’s compensation pathways is the Merit-Based Incentive Payment System (MIPS). The has implemented several new changes to the MIPS program physicians and clinicians should be aware of in order to obtain the highest possible payment bonus.
MIPS: Quality category
The new rule significantly changed the Quality category, which makes up 50 percent of a physician’s total score in MIPS. One change includes additional “topped out measures.” In 2018, CMS added the following topped out measures, which means that even if you submit a 100 performance rate on the measure, you can still only earn 7 out of the 10 possible points.
The topped out measures are:
1. Perioperative Care: Selection of Prophylactic Antibiotic – First or Second Generation Cephalosporin (Measure 21)
2. Melanoma: Overutilization of Imaging Studies in Melanoma (Measure 224)
3. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When indicated in ALL patients). (Measure 23)
4. Image Confirmation of Successful Excision of Image-Localized Breast Lesion (Measure 262)
5. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description. (Measure 359)
6. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Measure 52)
Thus, in order to fully maximize the Quality category, your practice will have to select more measures to make up the difference in points and ensure your Quality measures are not considered “topped out.” Other changes include the time a physician or clinician must collect data to be in compliance and points changes.
MIPS: Cost category
For 2018, the Cost category will now look at all the adjudicated claims submitted in the calendar year for a practice’s Medicare patients, which will count for 10 percent of a physician’s overall MIPS score.
The Medicare Spending Per Beneficiary (MSPB) Measure and the Total Per Capita Cost Measure are the only two measures considered in calculating a physician’s Cost score for MIPS. Since no additional data needs to be submitted to determine the Cost score, most physicians should focus on the other three MIPS categories—Quality, Clinical Improvement Activities, and Advancing Care Information—to gain the highest possible MIPS score.
In 2018, CMS developed a new way for physicians and clinicians to report their MIPS data—the “virtual group.” This is defined in the rule as, “a combination of two or more [tax identification numbers] (TINs) assigned to one or more solo practitioners or one or more groups consisting of 10 or fewer eligible clinicians that elect to form a virtual group for a performance period for a year.”
To form and join a virtual group, physicians or clinicians must be eligible under MACRA, and at least one member of a group of 10 or less physicians or clinicians must not be exempt from having to comply with MACRA to be eligible to join a virtual group.
For example, if a solo-practitioner is excluded from having to comply with MACRA, he or she would be ineligible to join a virtual group. The same is true for a group that wants to join a virtual group—if the group has more than 10 physicians or clinicians, or all members are excluded, the group cannot join a virtual group.
The benefits of joining a virtual group allow physicians and clinicians to band together to increase their MIPS scores. For example, if one physician’s Cost category is low, joining with another physician with a strong Cost category can allow both physicians, as a part of the virtual group, to increase their overall MIPS score.