Managing New MIPS Cost Category Changes For Specialty Practices

With the introduction of episode-based measures in the Cost category, many specialty providers are going to be seeing their Cost score affecting their overall MIPS score for 2019. With this new information coming out with the Final MIPS 2019 scores, many providers are asking how they can manage their score and maximize their MIPS points for the Cost category in the future.

Twenty (20) cost measures, including 18 episode-based measures, are used to evaluate performance in the Cost category for the 2020 MIPS performance period. CMS uses Medicare claims data to calculate cost measure performance, which means clinicians do not have to submit any data for this performance category. For MIPS 2020, many specialties have been excluded from the TPCC measure and it will no longer play a role in the final Cost score.

The two below measures are the ones we expect to have an impact on our providers:

• MSPB – A clinician must now have a minimum of 35 eligible cases. This change should be of general interest to all Nextech clients.
• Episode-based measures – The minimum case volume for procedural episode-based measures is 10. The minimum case volume for acute inpatient medical condition episode-based measures is 20. For Nextech clients, this mainly affects those in orthopedics and ophthalmology (see notes at the end of this blog for details).

What You Need to Do

The Cost category is a hard one to manage, and due to it being benchmarked on the current year’s performance, it is hard to monitor your success along the reporting year. There are a few things that can be reviewed to better control and maximize your Cost category score:

• Use Hierarchal Condition Category (HCC) codes
• Review your Cost score from 2018 and 2019 MIPS – details in your MIPS feedback reports
• Review cost data from other payers
• Put a larger focus on preventative care
• Manage where you refer patients for tests and specialty services
• Add patient relationship codes to your claims so your patients can be better attributed to you
• Lower overall costs by considering NP or PA for chronic care management

Now that providers will have a baseline score of how the cost category will be affecting their MIPS score, they can evaluate their current cost total and see how they fall along the benchmark and make needed adjustments in their service and fee models to try and maximize their scores to obtain the maximum amount of points in the Cost category for MIPS 2020.

Medicare Spending Per Beneficiary (MSPB)

The Medicare Spending Per Beneficiary (MSPB) measure evaluates solo practitioners and groups on their spending efficiency and is risk-adjusted to account for patients' risk profiles. Specifically, the MSPB measure assesses the average spend for Medicare services performed by providers/groups per episode of care. Each episode comprises the period immediately prior to, during, and following a patient's hospital stay. Each beneficiary MSPB episode is attributed to a single TIN-NPI.

The episode is attributed to the MIPS eligible clinician who billed the highest amount of Medicare Part B claims, measured by allowed charges, during the period between the admission date and the discharge date.

Special Note for Cataract Specialists

Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). For now, this change largely affects those clients in the ophthalmology specialty. We will post new updates if and when more episode-based measures are added.

The Routine Cataract Removal with IOL Implantation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for routine cataract removal with IOL implantation during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.

Special Note for Orthopedic Surgeons

Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). For now, this change largely affects those clients in the orthopedic specialty. We will post new updates if and when more episode-based measures are added.

Orthopedic surgeons will be evaluated on the cost of Knee Arthroplasty and Elective Primary Hip Arthroplasty procedures. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.

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