Merit-Based Incentive Program (MIPS) (12)
TIN stands for Tax Identification Number.
NPI stands for National Provider Identifier.
As a qualified registry by CMS, ReportingMD can report for you.
MIPS Years 1 & 2 (2017, 2018) – Physicians (MD/DO and DMD/DDS), PAs, NPs, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists (CRNAs).
MIPS Year 3 and beyond (2019) – Physical or Occupational Therapists (PT/OT), speech-language Pathologists, Audiologists, Nurse Midwives, Clinical Psychologists, Dieticians/Nutritional professionals.
Go to the CMS QPP website to check the MIPS eligibility by NPI. https://qpp.cms.gov/learn/eligibility
- First year of Medicare Part B participation: If an eligible clinician is newly enrolled in Medicare in 2018, they are not considered a MIPS eligible clinician. In 2019, they would be considered a MIPS eligible clinician and would need to report to avoid downward payment adjustments.
- Low patient/volume threshold: If an eligible clinician bills Medicare for ≤ $90,000 OR Provides care for ≤ 200 Medicare Part B patients in a year then they are not considered a MIPS eligible clinician.
- Certain participants in Advanced APMs: Certain participants in Advanced Alternative Payment Models (APMs) if considered a Qualifying Participant (QP) are not considered MIPS eligible clinicians. Partial QPs will have the option to elect whether or not to report under MIPS, which determines whether or not they will be subject to the MIPS adjustments.
If a MIPS eligible clinician does NOT report anything for the MIPS program for the 2018 reporting year, they will be subject to a 5% downward payment adjustment in 2020.
This number increases in 2019 and beyond:
- 2019: +/- 7% payment adjustment
- 2020: +/- 9% payment adjustment
Per the final rule, 2018 has also been classified as a “transition year” under MIPS. For the 2018 transition year, MIPS eligible clinicians still have the ability to transition to MIPS reporting at their desired pace. MIPS eligible clinicians can choose to report a level to just avoid a penalty, to receive a small incentive, or to be considered exceptional and therefore receive a larger incentive.
MIPS Quality – worth 50%
MIPS Cost – worth 10%
MIPS Improvement Activities – worth 15%
MIPS Advancing Care Information – worth 25%
If a MIPS EC (eligible clinician) or group practice is interested in some incentive eligibility through MIPS quality reporting, what are the criteria for reporting?
To be eligible for any incentive, a provider or group practice would need to achieve a MIPS Composite Performance Score (CPS) higher than 15 points. One method to do this is through reporting on the MIPS quality category. A provider or group practice would report 6 individual measures and at least 1 of the 6 measures being an outcome measure. If no outcome measure is applicable then a high priority measure would need to be reported in lieu of an outcome measure. The measures would need to be reported for a full year. The provider or group practice would need to report enough to meet the data completeness threshold of 60%. If a provider or group practice reported at least 60% of all payer eligible events for a full year for 6 measures with 1 being an outcome measure, then the provider or group practice would achieve at least 18 points (6 measures x 3 points each). Activities that would increase beyond 18 points would include: selecting measures that can be scored against the benchmark deciles, reporting on the Improvement Activities (IA) category, or reporting on the Promoting Interoperability (PI) category.
ReportingMD can help you decide which method of reporting works better for your practice.
Individual reporting happens when a provider or group of providers reports for pay-for-performance programs at an individual level. The providers would report all eligible events that they billed for according to the measure specifications. For example, for measures that are once per patient per reporting period, if a patient saw 5 different clinicians at a practice, each of the 5 clinicians would need to report on that patient.
Group reporting occurs when a group of clinicians report at the Tax ID Number (TIN) level. In the case of once per patient per reporting period measures, even if a patient saw 5 difference clinicians at a practice, that patient would only be reported once when reporting at the group aggregated level.
Use the following outline to determine how to read the specifications.
Eligible Instances: The number of instances (patients, visits, episodes, etc.) that meet all eligibility criteria for a specific measure of interest, as explained in the 2018 Measure Specifications Manual for Individual Measures.
Example of a measure denominator description, from the 2018 MIPS Registry Measure Specifications Manual:
- Measure #12 (NQF 0086): Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
The numerator must detail the clinical quality action expected that satisfies the condition(s) and is the focus of the measurement for each patient, procedure or event established by the denominator. The numerator options are “MET” and “NOT MET” for all measures with some measures having the additional option of “DENOMINATOR EXCEPTION”. Under “Numerator” in the 2018 Measure Specifications Manual, the options will be separated by “OR”.
Performance Met: The number of eligible instances that meet the “MET” criteria.
Performance Denominator Exception: The number of eligible instances that meet the “DENOMINATOR EXCEPTION” criteria. *This does not apply to every measure.
Performance Not Met: The number of eligible instances that meet the “NOT MET” criteria.
- Desired Performance Rate: 0.00%
- A lower calculated performance rate for an inverse measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
- Desired Performance Rate: 100.00%
- A higher calculated performance rate for a non-inverted measure indicates better clinical care or control. The “Performance Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 100%, as quality increases. For non-inverted measures, a rate of 0.00% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.