The rules and requirements have changed each year of the MIPS program. Here is a list of the major modifications from previous years. More information about these topics can be founded in the referenced section:

• Facility-based scoring (Quality and Cost)
• Opt-in (Eligibility)
• Three low-volume threshold criteria (Eligibility)
• Promoting interoperability overhaul (Promoting Interoperability)
• Multiple submission types allowed within a performance category (Quality)
• Claims submission can only be utilized by small practices (Submission Mechanisms)
• Removal of normal dose limits quality measure (Quality)

Physicians can look up eligibility on the QPP Participation Lookup tool based on their National Provider Identification (NPI) number.

MIPS applies to clinicians billing more than $90,000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare Part B enrolled patients a year AND more than 200 Medicare Part B covered services. Billing and patient volumes are based on 12-month historical data (September-August). The new requirements allow for physicians to opt-in to MIPS if they meet at least 1 of the 3 criteria. Those opting in will receive the related payment adjustment 2 years later. Those that do NOT meet any of the criteria can voluntarily report data; however, they will not receive a payment adjustment.

Eligible clinicians include:

• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Certified registered nurse anesthetists
• NEW Registered dietician or nutrition professional
• NEW Physical therapists
• NEW Occupational therapists
• NEW Qualified speech-language pathologists
• NEW Qualified audiologists
• NEW Clinical psychologists

There are many requirements and rules in MIPS, however there is still a large amount of flexibility for participating in the program.

Program Goals

The level of participation in the MIPS program is dependent on the practice’s financial goals.  There is a different level of effort if a practice wants to achieve 30 points to avoid the 7 percent penalty or achieve more points to receive a larger payment adjustment. In this budget-neutral program, the funds collected from the penalties will be utilized to pay for the positive payment adjustments. If an individual or group achieves over 75 points, they will be eligible for the exceptional performance bonus, funded through a separate source. Having a goal in mind prior to determining the remainder of the participation elements is key.



As the Performance Threshold increases year to year, it is harder to avoid the penalty. In 2019, practices must submit data from more than one performance category to achieve 30 points. 

Individual vs Group vs Virtual Group

There are three reporting options for MIPS based on TIN/NPI combination. The decision to report as an individual, group or virtual group is part of your MIPS strategy and will be unique to your practice.
 

	Individual	Group	Virtual Group
Definition	A single NPI tied to a single TIN	A single TIN. All NPIs who have assigned their billing rights to a single TIN would be part of this group	A physician or group of less than 10 that has joined with another similar group (regardless of specialty)
Impact on Payment Adjustment	Your performance will directly impact your payment adjustment	A group’s performance is assessed across all of the MIPS performance categories and the group will get one payment adjustment based on the group’s performance	A Virtual Group’s performance is assessed across all of the MIPS performance categories and the virtual group will get one payment adjustment based on the virtual group’s performance

MIPS provides several data submission options, and most are available for Quality, Improvement Activities and the Promoting Interoperability performance categories.  Beginning in 2019, data can be submitted via multiple mechanisms within a performance category. For example, a physician can utilize a registry to report some quality measures and claims to report others. If the same measure is submitted via multiple mechanisms, the one with the greatest number of measure achievement points will be selected for scoring.

In 2019, only small practices (≤15 eligible clinicians) can use Claims for data submission. It’s not an option if you’re participating in MIPS as a large group. Claims data is only available for the Quality performance category. If you choose to submit quality data through claims, Quality Data Codes (QDCs) will need to be added to denominator eligible claims to show that the required quality action occurred, or exclusion applied. QDCs are specified Current Procedure Terminology (CPT) II codes (with or without modifiers) and G-codes used for submission of quality data for MIPS. When these codes are included on your claims form, it identifies your selected quality measures for CMS. You’ll also need to apply encounter codes, including ICD-10-CM, CPT Category I, or Healthcare Common Procedure Coding System (HCPCS) codes. These codes show which patients should be added toward the denominator/numerator of the quality measure. 

A Registry is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. Each registry is different; however, most will collect data for the Quality, Improvement Activities and Promoting Interoperability performance categories. A full list of CMS-approved entities can be found on the CMS website.

A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. The QCDR reporting option is different from a Registry because it is not limited to quality measures within MIPS. The QCDR can develop and submit QCDR measures for CMS consideration and approval. The QOPI Reporting Registry is available for radiation oncology and medical oncology practices. See a full list of the 2019 measures. The QOPI Reporting Registry collects and reports data for the Quality, Improvement Activities and Promoting Interoperability performance categories.

An Electronic Health Record (EHR) can provide two ways to submit data to CMS.  Either the vendor can submit MIPS data to CMS on your behalf or the vendor can provide the clinician with a Quality Reporting Document Architecture (QRDA) file which you can submit on your own through the CMS Portal. The capability and available options are vendor specific, so please check with your EHR vendor to understand the available options.  CMS approves EHR data submission for Quality, Improvement Activities and Promoting Interoperability performance categories.

The CMS Portal is a secure internet-based data submission mechanism available for all physicians and groups. To sign into the CMS portal, you will need your Enterprise Identity Management (EIDM) credentials and have the appropriate user role associated with your organization. The EIDM login is the same login used during PQRS submission.  Password reminders and registration for new users can be found on the QPP webpage. You will be able to report as either a group or individual for each TIN associated with the account. Attestation is available for the Improvement Activities and Promoting Interoperability performance categories. For the Quality performance category, users will be able to import an approved data file.

The 2019 performance year includes two bonus opportunities. Both were introduced during the 2018 performance year; however, one has been modified for 2019:
 

• Small Practice Bonus – MODIFIED - 6 points - Practices comprised of 15 or less eligible clinicians will automatically receive this bonus in the numerator of the Quality performance category score.
• Complex Patient Bonus – up to 5 points – CMS will automatically calculate and award this bonus based on two indicators:
  • Medical complexity as measured through Hierarchical Condition Category (HCC) risk scores*, and
  • Social risk as measured through the proportion of patients with dual eligible^† status.

The bonus will be calculated by adding the HCC Score, capped at 3-points, and the dual eligible ratio, multiplied by 5. You do not need to submit any additional information for CMS to be awarded this bonus.

*HCC Risk Score is a payment methodology based on risk used by CMS to adjust payments at the patient level. This means that 2 patients within the same community can have a different payment rate based on several factors relating primarily to the amount of risk—or work—it takes to maintain the health of a patient. In the 2018 QPP proposed rule, CMS stated that the average HCC score for radiation oncology is 1.79.

^†Dual Eligible refers to beneficiaries qualifying for both Medicare and Medicaid benefits. CMS has stated that the average dual eligible ratio for radiation oncology is 22.2 percent.

Sample Calculations
General Equation: HCC + (Dual Eligible Ratio x 5) = Complex Patient Bonus
Using CMS radiation oncology averages: 1.79 + (0.22 x 5) = 2.89 Complex Patient Bonus Points

Each practice will have its own unique combination of indicators based on the population it serves and are capped at 5 points.
 

Clinicians must report either six measures or the three in the Radiation Oncology measure set.  In prior years there were four in the measure set, however, CMS removed the Dose Limits to Normal Tissue measure from MIPS due to its high-performance rate.

*High priority measures are those categorized as outcome, appropriate use, patient safety, efficiency, patient experience and care coordination.

Overview The following equation can be utilized to calculate the quality score:   Quality Score = Measure Points + Bonus Points                           Total Available Measure Points     The following equation can be utilized to calculate the quality category points awarded towards the composite performance score (CPS):   Quality Category Points towards CPS = (Quality Score + Improvement Score) x (Category Weight)   Measure Points Each measure will receive a total score from 0 to 10 points based on reporting and performance. Zero points will be awarded if no data is submitted. Three baseline reporting points will automatically be awarded if any data is submitted by a small practice. Zero to seven additional achievement points will be added to the three baseline points based on a physician/group’s performance against a benchmark, but only if the case minimum (20 cases) is met.  As a reminder, physicians must submit data on 60 percent of all patients (regardless of payer) that meet the measure’s denominator criteria for a full year. The only exception to this requirement is for measures reported via claims, in which case, physicians must submit data on 60 percent of all Medicare Part B patients that meet the measure’s denominator during the reporting period. To earn achievement points, physicians need to submit a minimum of 20 cases per measure and a measure benchmark must exist. If a benchmark was not available from historical data, CMS will attempt to calculate benchmarks based on 2019 performance data. If a physician submits less than 20 cases for a measure or a measure does not have a benchmark, no achievement points will be awarded, and the physician will only receive the three baseline points for that measure. Bonus Points There are three bonus point opportunities in the Quality category. Bonus points will be added to a clinician’s overall Quality performance category points. Small Practice Bonus Six bonus points are added to the numerator of the Quality performance category for MIPS eligible clinicians in small practices (≤15 eligible clinicians) who submit data on at least 1 quality measure. End-to-end reporting One bonus point, per measure, if quality data is reported directly from an EHR to a qualified registry or QCDR. To earn the end-to-end bonus for 2019, practices must use 2015 Certified Electronic Heath Record Technology (CEHRT).  This would include Aria 15.5 and Mosaiq 2.7. Additional measures One bonus point for each additional high priority measure. Two bonus points for each additional outcome and patient experience measure. Total Available Measure Points The total available measure points will be 30 or 60 depending on whether you report the three measures in the radiation oncology measure set or six independent quality measures. Improvement Score The improvement score can only be awarded if a physician or practice has participated in the program for two consecutive years and is awarded based on performance in the Quality category compared to the previous MIPS performance period. To allow flexibility for physicians and practices to choose different measures from year to year, the improvement score is based on the overall Quality score instead of the performance on specific measures. If a MIPS eligible clinician has a previous year Quality score less than or equal to 30 percent, CMS will compare 2019 performance to an assumed 2018 Quality performance category score of 30 percent. Improvement Score = (2019 Quality Score - 2018 Quality Score)  x10                                                 2018 Quality Score     The improvement score cannot be negative, meaning that a practice that did not have an increase in performance would receive zero improvement points. Facility-based Score Beginning in 2019, clinicians that furnish 75 percent or more of their covered professional services in POS 21, 22 or 23, and have at least a single service billed with POS 21 (inpatient hospital) or 23 (emergency room) can use the Quality and Cost scores with the facility’s Value-Based Purchasing score. Practices will still need to report on the Improvement Activities and Promoting Interoperability category separately.

If an eligible physician furnishes more than 75 percent of their covered professional services in an on-campus hospital (POS 22), then CMS will consider them exempt from PI. CMS makes this determination based on claims data for a period prior to the performance year. The hospital-based designation can be found on the MIPS eligibility status. You will not need to request an exemption.

For physicians practicing in free-standing centers, you can apply for an exemption because of hardships, including:

• Insufficient internet connectivity
• Extreme and uncontrollable circumstances
• Lack of control over the availability of CEHRT
• Small practice

To receive the hardship exemption, physicians need to submit an application& explaining why the EHR technology is not available. The application is typically released in Summer of the performance year.

If exempt, this category weight is reduced to 0 percent and redistributed to the Quality performance category. Despite the exemption, eligible physicians who want to pursue reporting PI measures can still report and get credit.

This performance category has been reworked in 2019 to align with other federal payment systems.

For 2019 PI, eligible practices must use 2015 Edition Certified Electronic Health Records Technology to complete reporting. The complete list of certified systems and modules can be found on the ONC website.

CMS finalized the following measures that are required for all clinicians.



Many radiation oncology practices already report to a clinical data registry, but the National Institutes of Health has compliled a list that might help identify new registries.

A clinician can earn up to 110 PI measure points as the sum of these components:

• Performance Points: Up to 100 total points from non-bonus measures, where each measure is worth 10, 20, or 40 measure points. Performance rates are scored on a static decile scoring scale where, for instance, a performance rate of 50% earns 5 points out of 10, 66% earns 7 points out of 10 (CMS rounds 6.6 points up to 7 points), and a performance rate of less than 5% would receive a score of 1 if at least one patient was reported in the measure’s numerator. The Public Health and Clinical Data Exchange measures are scored as yes/no.
• Bonus Measure Points: Up to 10 total bonus points can be earned for reporting two optional opioid-related measures worth 5 points each.

In addition, an annual security risk analysis must be reported in order score any points in the category.  Claiming an allowed measure exclusion causes the measure’s points to be shifted to a different measure. If a clinician does not report either a numerator of 1 or a “yes” for a required non-bonus measure or claim an exclusion for it, then the entire category would receive a score of 0.

There are over one hundred activities to choose from in 2019. How activities are weighted is an important factor in determining the score and how best to satisfy the minimum requirements. For a full list of the activities, visit CMS’s QPP website.

While only attestation of activity completion is necessary for reporting, practices should maintain documentation to demonstrate consistent and meaningful engagement within the performance period. In the event of an audit, documentation must be presented.

RO-ILS: Radiation Oncology Incident Learning System®, sponsored by ASTRO and AAPM, is a part of Clarity PSO, a federally listed patient safety organization. A medium weighted activity within the “Improvement Activity” (IA) Performance Category is “Participation in an AHRQ-listed patient safety organization” (Activity ID = IA_PSPA_1). There is no fee to participate in RO-ILS, but the facility must sign an agreement with Clarity PSO so start the contracting process now. Join the more than 400 facilities enrolled in RO-ILS.

For this activity, CMS suggests “documentation from an AHRQ-listed patient safety organization (PSO) confirming the eligible clinician or group's participation with the PSO.” Therefore, upon request, Clarity PSO will send a Letter of Participation stating that your practice or facility is actively participating in RO-ILS during the reporting period. Please email radoncsupport@claritygrp.com to request a RO-ILS Letter of Participation. Letters will be sent later in the year.

Additionally, you can use RO-ILS towards fulfilling the Part IV Physician Quality Improvement (PQI) Maintenance of Certification (MOC) requirements established by the American Board of Radiology. This meets an additional medium-weighted improvement activity (Activity ID = IA_PSPA_2).

ASTRO’s Accreditation Program for Excellence (APEx) focuses on a culture of quality and safety, as well as patient-centered care. Evidence indicators required for APEx accreditation map to 15 improvement activities. One of these activities is participation in MOC Part IV, which can be accomplished with the APEx MOC template. The self-assessment component of the program can satisfy all the requirements for the Improvement Activities performance category.

In the event of an audit, proof of completion of each activity needs to be maintained. The APEx MIPS IA Table includes CMS recommended documentation as well as the mapped APEx Standard.

Activities are either medium-weighted (worth 10 points) or high-weighted (worth 20 points) — most activities are listed as medium-weighted. Clinicians can report any combination of medium and high-weighted activities to meet the necessary points for full credit.
 
As an individual or group with the small (15 or less), Rural or Health Professional Shortage Area (HPSA) designations only need a total of 20 points to receive full credit in the IA category. This can be accomplished by attesting to either one high-weighted activity or two medium-weighted activities. 
 
Practices certified as patient-centered medical homes (PCMH) automatically receive full credit and do not need to report additional activities.
 
All other practices must score a total of 40 points to receive full credit in the IA category. 

The Medicare Spending per Beneficiary (MSPB) cost measure assesses the cost to Medicare of services performed by an individual clinician during an MSPB episode. An MSPB episode includes all Medicare Part A and Part B claims falling in the episode “window,” which begins three days prior to a hospital admission and ends 30 days after the patient is discharged from the hospital.

Episodes will be attributed to the clinician who provided the Part A and Part B services to a beneficiary during the admission.

• Clinicians who do not see patients in the hospital will not be attributed to any episodes and not scored on the measure
• Clinicians must be attributed to at least 35 cases to be scored on the measure

Based on CMS’ calculations for this measure, we believe it could be likely that large radiation oncology practices, submitted as a group, could have the necessary patient counts for this measure in 2018.

The Total per capita cost measure evaluates the overall cost of care provided to beneficiaries attributed to clinicians, as identified by a unique Taxpayer Identification Number/National Provider Identifier (TIN-NPI). The Total Per Capita Costs for All Attributed Beneficiaries measure can be reported at the TIN or the TIN-NPI level.

• The beneficiary is attributed to the primary care physician (PCP) who provided the most primary care services during the performance period.
• If a PCP did not bill any primary care services for a beneficiary, then the beneficiary is attributed to the specialist who provided the most primary care services during the performance period
• Clinicians must be attributed to at least 20 unique beneficiaries to be scored on this measure.

Based on CMS’ calculations for this measure, we believe it could be likely that large radiation oncology practices, submitted as a group, could have the necessary patient counts for this measure in 2018.

Cost will be measured using administrative claims data, if the case minimum of attributed patients is met for a measure and a benchmark has been established. Benchmarks are based on data from the current performance year and utilized to compare the performance of MIPS eligible clinicians and groups. The Cost score is the average of the two measures. If only one measure can be scored, the score of that one measure will be the entire Cost performance category score. In the case where neither measure can be scored, which is likely for many radiation oncologists, the 15 points from the Cost category will be re-weighted to the Quality performance category.
 
Facility-based Score
Beginning in 2019, clinicians that furnish 75 percent or more of their covered professional services in POS 21, 22 or 23, and have at least a single service billed with POS 21 (inpatient hospital) or 23 (emergency room) can use the Quality and Cost scores with the facility’s Value-Based Purchasing score . Practices will still need to report on the Improvement Activities and Promoting Interoperability category separately.