There are four components to the Medicare Incentive Payment System (MIPS): Quality (45% of total score), Promoting Interoperability (25% of score), Improvement Activities (15% of score), and Cost (15% of score).

The Final Rule, published November 15, 2019, will take effect on January 1, 2020. The clinician's eligibility for MIPS will not change for CY 2020. The exemption also remains with the low volume threshold and eligible clinical participants. 

Cost is calculated from claims submitted and is based on two parts: cost measures that assess the beneficiary's total cost per capita of care (TPCC) during the year, or during a hospital stay, and/or during the newly added 10 episode-based care. The Total Per Capita Costs for all attributed beneficiaries (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that 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).

CMS is changing the attribution methodology for TPCC to more accurately identify clinicians who provide primary care services. TPCC requires a combination of (1) an E/M service; and (2) general primary care services or a second E/M service from the same clinician group with the addition of service category exclusions and specialty exclusions. Specifically, certain candidate events are excluded if they are performed by clinicians who (1) frequently perform non-primary care services (for example, global surgery, chemotherapy, anesthesia, radiation therapy); or (2) are in specialties unlikely to be responsible for providing primary care. The medical attribution will be different for individuals and groups and will be defined in the applicable measure specifications of primary care to a beneficiary (for example, podiatry, dermatology, optometry, ophthalmology). 

The revised total per capita cost measure continues to use payment standardized prices to account for differences in Medicare payments for the same service across Medicare suppliers for all services included in the measure, including for Part B drugs. The total per capita cost measure focuses on primary care by design and includes all costs to provide a broad assessment of a clinician's management of the overall health of a patient, rather than a specific condition. In managing a patient's complete health, clinicians measured under the total per capita cost measure are incentivized to conduct patient follow-up, coordinate care among specialists, offer necessary referrals, and actively diagnose patients. Clinicians managing patients' care are the focus of this measure and are compared to their peers performing similar roles.

The revised MSPB clinician has been refined to ensure effective attribution and compare similar clinicians. This is achieved by distinguishing between medical episodes and surgical episodes and risk adjusting for these episodes. These refinements allow for more accurate comparisons of predicted episode spending as clinicians are compared to other clinicians treating patients with similar characteristics, rather than being compared to all clinicians.

The changes to the attribution method of the revised MSPB clinician measure involves the use of separate attribution methods for medical and surgical episodes to identify the clinician(s) responsible for providing these different types of care and properly capture costs for more or less expensive episodes. The new methodology shifts attribution of episodes toward specialties that are more likely to be involved in managing the course of a patient's care, rather than attributing clinicians who do not provide the overall care management for a beneficiary. Additionally, the risk adjustment for the revised measure is compared within each Major Diagnostic Category (MDC), and not between medical and surgical episodes. It is possible for specialties such as pathology to be attributed the revised MSPB clinician measure, as long as the pathologist is involved in the inpatient care of a patient and meets the attribution requirements. 

The MSPB clinician will have a different methodology for surgical and medical episodes. There are no changes for attribution in episode-based measures (existing and new). The revised MSPB clinician measure assesses the cost to Medicare as a result of the services performed by an individual clinician during an MSPB clinician episode, which comprises the period immediately prior to, during, and following a patient's inpatient hospital stay. The measure was refined to exclude a defined list of services that are unlikely to be influenced by the clinician's care decisions and that are considered clinically unrelated to the management of care. The service exclusion rules are defined specific to the MDC of the index admission and were developed with expert clinical input from the MSPB Service Refinement Workgroup. Clinicians can choose how to participate in MIPS and have the option to report as a group or as individuals. Under the revised MSPB clinician measure, an episode can be attributed to multiple clinicians or clinician groups. The measure calculation risk adjusts each clinician's or clinician group's observed costs for patients with the same observable characteristics among their peers, rather than to a pre-defined standard. Given that the inpatient hospital setting is an important contributor to overall Medicare spending, gauging the efficacy of this spending requires measuring the cost performance of clinicians providing care at hospitals. The MSPB clinician measure provides valuable context for such progress in efficiency by measuring costs of care from a holistic perspective at the beneficiary level. 

The ten episode-based measures added for 2020 include Acute Kidney Injury regarding inpatient dialysis, Elective Primary Hip Arthroplasty, femoral or inguinal hernia repair, renal dialysis access creation, Inpatient chronic obstructive pulmonary disease (COPD) exacerbation, lower GI hemorrhage (applies to groups only), lumbar spine fusion for degenerative disc disease 1-3 levels, lumpectomy Partial Mastectomy, simple mastectomy, non-emergent CABG, and renal or ureteral n\stone surgical treatment. The case minimum is still at 10 for procedural episodes and 20 for acute inpatient medical condition episodes.

Maxine Lewis, CMM, CPC, CPC-I, CPMA, CCS-P, is a member of the National Society of Certified Business Consultants and is a nationally recognized lecturer, author, and consultant in the healthcare industry, combining more than 40 years of practical experience in the medical office with an in-depth understanding of coding, reimbursement, and management issues of the medical profession.