What Is the Merit-Based Incentive Payment System (MIPS)?

January 19, 2022 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Practice Management, Medical Billing Company

If you’re a Medicare provider, then you might want to know about MIPS—a healthcare incentive program that helps gather data of quality and performance outcomes over time while rewarding medical practices that demonstrate improvements. This program utilizes a “score” system comprised of four categories.

Learn more about these categories and how to get involved with MIPS!


What Is the Merit-Based Incentive Payment System (MIPS)?

The Merit-Based Incentive Payment System (MIPS) determines Medicare payment adjustments; by utilizing a scoring system, eligible clinicians (ECs) might earn a payment bonus, penalty, or no adjustment. This is one of two paths for Medicare B providers to operate on a performance-based payment system under the Quality Payment Program (QPP). 

MIPS is the umbrella term for what was formerly three separate programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM) program, and the Medicare Electronic Health Record (EHR) Incentive Program all amalgamated in 2017 to form one streamlined program known as MIPS.

ECs are able to decide if they want to report to MIPS as an individual or as part of a group. If reporting as an individual, the clinician would submit data under their National Provider Identifier (NPI) that is connected to their Taxpayer Identification Number (TIN). When reporting as a group, each clinician’s unique NPI is attached to a shared TIN.

It’s important to note that there are three exclusions of providers from MIPS eligibility:

  • Providers participating in an Alternate Payment Methods, as defined by MACRA
  • Clinicians who bill less than $90,000 in Medicare beneficiaries in a designated period OR provide care for fewer than 200 Medicare patients a year are exempt due to low volume
  • Providers who enroll in Medicare for the first time during a performance year are exempt until the next subsequent performance year

What Are the 4 MIPS Score Categories?

Since MIPS is inherently connected to performance, CMS has a method for assessing performance through the use of four categories, including:

Quality: 40% of MIPS Score

For this category, there are 6 types of data to submit in order for your score to be calculated, including:

  • Electronic Clinical Quality Measures (eCQMs): This quality is measured in certified electronic health record (CEHR) technology 
  • MIPS Clinical Quality Measures (CQMs) 
  • Qualified Clinical Data Registry (QCDR) Measures: This facet of quality is handled by CMS-approved entities that essentially measure and analyze medical or clinical data in an effort to track patients and diseases while facilitating improved quality of care
  • Medicare Part B claims measures
  • CMS Web Interface measures: This platform, available because of CMS, lets groups, virtual groups, and APM organizations of 25 or more ECs submit data at the beneficiary level for a unique set of measures; learn how to register for it here
  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey: If your entity meets the sampling criteria for this survey, it can count as 1 of the 6 required measures, or it can be in conjunction with the 10 measures needed for the CMS Web Interface; learn more about it and register here

When reporting for this component of your MIPS score, you’ll need to submit acquired data for at least 6 measures—including at least 1 outcome measure—which can be mixed and matched, or you’ll need to complete a specialty-specific set of data requirements. To ensure comprehensive data, you’ll need to report on at least 70% of patients who qualify for each measure. 

MIPS also has the opportunity for your medical practice to score bonus points if you:

  • Submit two or more outcome or high priority quality measures
  • Or use certified EHR technology (CEHRT) to collect measure data and meet end-to-end electronic reporting

Furthermore, you can earn an additional 10 percentage points based on improvement in the same category year-over-year. 

Overall, this category requires data be collected relating to patient outcomes, the correct use of medical resources, patient safety, efficiency, patient experience, and care coordination.

Promoting Interoperability: 25% of MIPS Score

This category essentially measures how well electronic health systems are utilized in a medical practice setting with a particular emphasis on how information is securely shared to promote interoperability among patients and healthcare systems. For 2021, you’re required to use CEHR that meet 2015 certification criteria.

To promote healthcare access and interoperability, factors like the following are points of improvement:

  • Patient access to their health information
  • The exchange of information between clinicians and pharmacies
  • The systematic collection, analysis, and interpretation of healthcare data

It should always be a priority to boost patient education and encourage patient engagement in their health and wellness journey. Making their health information accessible via electronic means helps facilitate this engagement.

Furthermore, streamlining access to patient information across platforms and various entities helps every provider involved deliver better care.

Cost: 20% of MIPS Score

As you might guess from the name of this category, this measures the cost of care over the course of the year based on your Medicare claims. Cost looks at 20 different measures including two holistic measures:

  • Medicare Spending Per Beneficiary (MSPB): This assesses Medicare Parts A and B costs in the 3 days prior to an inpatient hospitalization, the duration of the hospitalization, and 30 days after an inpatient is released from the hospital
  • Total Per Capita Cost (TPCC): Assesses the total cost of a singular beneficiary over the course of a year

The other 18 measures relate to procedures and include:

  • Elective outpatient percutaneous coronary intervention (PCI; procedural)
  • Knee arthroplasty (procedural)
  • Revascularization for lower extremity chronic critical limb ischemia (procedural)
  • Routine cataract removal of intraocular lens (IOL) implantation (procedural)
  • Screening/surveillance colonoscopy (procedural)
  • Intracranial hemorrhage or cerebral infarction (acute inpatient medical)
  • Simple pneumonia with hospitalization (acute inpatient medical)
  • ST-elevation myocardial infarction (STEMI) with percutaneous coronary intervention (PCI; acute inpatient medical)
  • Non-emergent coronary artery bypass graft (CABG; procedural)
  • Femoral or inguinal hernia repair (procedural)
  • Elective primary hip arthroplasty (procedural)
  • Lumpectomy, partial mastectomy, simple mastectomy (procedural)
  • Lumbar spine fusion for degenerative disease, 1-3 levels (procedural)
  • Hemodialysis access creation (procedural)
  • Renal or ureteral stone surgical treatment (procedural)
  • Acute kidney injury requiring new inpatient dialysis (procedural)
  • Lower gastrointestinal hemorrhage or cerebral infarction (acute inpatient medical)
  • Inpatient COPD exacerbation (acute inpatient medical)

It’s important to note that no additional reporting action is required to submit for this category.

Improvement Activities: 15% of MIPS Score

In order to earn full credit in improvement activities, you must submit one of the following combinations of activities:

  • 2 high-weighted activities—these assess the greatest impact on patient safety, care, health, overall wellbeing, etc. and require tremendous time and resources to track
  • 1 high-weighted activity and 2 medium-weighted activities
  • 4 medium-weighted activities

High-weighted activities are worth 20 points and medium-weighted activities are worth 10 points. However, if you’re assigned Special Status, these point values could be doubled. Find out more about Special Status here.

This particular measuring period is over the course of 90 days and aims to consistently measure overall improvement efforts related to patient care quality, process efficiency, and access to care.

Final Scoring

Upon submitting your information, CMS will calculate your MIPS score over the performance period. This score ultimately determines the outcome of the adjustment applied to your Medicare Part B claims; it could be positive, negative, or neutral.

Boost Patient Care Quality By Partnering with NCG!

Want to participate in MIPS but wish you had more time and resources to attend to improving patient care quality? If you find yourself running on fumes due to a heavy administrative burden, then partnering with a medical billing firm would benefit you and your medical practice tremendously.

Handing off this significant and important—yet incredibly tedious—component of your practice and overall revenue cycle to a trusted partner gives you more time to do what you do best: deliver great patient care.

With four decades of experience helping healthcare practices improve their billing and coding efficiencies, NCG Medical can help protect your practice from the potentially devastating effects of a medical billing audit. Our team of certified medical coders, MBA, and CPAs can also help you streamline your practice management to improve efficiencies, trim costs, and boost revenue. Contact our team today!

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