HAP Radiology Billing and Coding Blog

How Important Is The MIPS Cost Category to Radiology Practices?

Posted: By Richard Morris on March 8, 2018

How Important Is The MIPS Cost Category To Radiology Practices Heatlhcare Administrative PartnersThe Centers for Medicare and Medicaid Services (CMS) threw a surprise into the Quality Payment Program (QPP) Final Rule for 2018 when it included the Cost Category as 10% of the MIPS Final Score for 2018 reporting.  The QPP Proposed Rule issued a few months earlier stated that Cost would be zero-weighted for 2018 as it had been in 2017.  So what does this mean for radiology?

How will adding the Cost Category affect the Final Score?

The Cost Category score will contribute 10% of the MIPS Final Score.  The Quality Category is nominally 50%, Improvement Activities (IA) is 15% and Advancing Care Information (ACI) is 25%.  Most radiologists will be exempt from ACI reporting, so its 25% will be shifted to Quality, making Quality worth 75%.  Radiologists would expect to score very well on Quality and IA but now with Cost in the mix its 10% could bring down their total score to the point where a positive adjustment is out of reach unless they can produce a high score in the Cost Category.

How will Cost be evaluated?

CMS will evaluate individual Eligible Clinicians (ECs) and group practices on two measures in 2018: (1) Total Per-capita Cost of Care (TPCC) for attributed beneficiaries and (2) Medicare Spending per Beneficiary (MSPB).  The first measure will affect providers such as those in primary care and internal medicine.  The provider who delivers the most office-based and non-inpatient Evaluation and Management services to a patient is assigned that patient as a designated beneficiary.  This provider could be a specialist, such as a cardiologist, if that specialist delivered more services than the patient’s primary care physician.


Medicare Spending per Beneficiary (MSPB) looks at the total cost of an inpatient stay and assigns the admission to the provider that charges the highest amount to Medicare under Part B billing.  The costs for the episode of care include not only those incurred while an inpatient, but also the cost for all outpatient services incurred 3 days prior to admission and 30 days following discharge. 

How can radiologists have any hospital admissions?

Surprisingly, radiologists can be charged with hospital admissions under the MSPB methodology.  A hospital admission is assigned to the provider that bills the highest dollar amount during the patient’s episode of care.  It’s easy to see that diagnostic imaging could be a big part of pre-admission services, whether the patient is an outpatient or in the emergency department.  During the stay, such services as interventional radiology and radiation oncology will contribute greatly to the patient’s total cost of care.


The best way to understand your practice’s exposure is to review the 2016 Quality and Resource Use Reports (QRUR) available from CMS.  Table 5B in the QRUR reports lists all patients attributed to the practice. 

Watch the free video 'MIPS and the QPP in 2018: The Journey Continues'

How do we report Cost?

There is no separate reporting required, as CMS will gather the data taken from the Medicare claims submitted routinely by the practice.  When sufficient data exists, there will be a 1-percentage point bonus available for improvement year over year.  Even though Cost was not a factor until now, CMS has the data to calculate improvement and will apply it when warranted.

How do the Cost measures become MIPS scores?

The TPCC score is calculated by CMS by totaling all of the annual Part A and Part B costs for the beneficiaries assigned to the practice and dividing that cost by the total number of assigned beneficiaries.  A practice needs 20 episodes for the TPCC to count toward the MIPS Cost Category score, and its unlikely that many radiologists will accumulate that number of TPCC episodes.


The MSPB score is calculated by CMS by totaling all of the costs for attributed patients and dividing that cost by the number of episodes of care.  The resulting score will be measured against a peer group and scored accordingly.  A practice needs 35 episodes of care for the MSPB measure to count toward the MIPS Cost Category score.


Radiologists that qualify for the MSPB score but not the TPCC will have the MSPB score as their total Cost Category score.  In the event the practice does not qualify for either, then the Cost Category’s 10% weight will be reassigned to the Quality Category.

How do we prepare?

Use the QRUR to understand your practice’s historical data.  From the data, you might be able to recognize a pattern of high costs and see how your cost scores compare with the national average. Try to understand why these patients are being attributed to your NPI or Tax ID under the two attribution methodologies. 


The QRUR can be used to risk-stratify attributed beneficiaries’ hierarchical condition category (HCC) percentile rankings cross-checked with 30-day readmission rates to identify potential cost-saving initiatives, such as transitional care management.


The 2018 measurement year is the first one where the Cost Category is in effect, and it carries a weight of 10% toward the final MIPS score.  In 2019, the category is scheduled to increase to a much more significant 30% of the final score.  Now that radiologists understand how they might be participating in this category, it becomes important to learn how to manage your practice’s score. For regular updates, subscribe to this blog now.


Richard Morris is the Director of Value-Based Strategy at Healthcare Administrative Partners. His areas of expertise include healthcare payment innovation and the Quality Payment Program (QPP). 


Attending RBMA Paradigm in San Diego?  Join our presentation on Friday, April 6th, at 11 AM to learn how we're utilizing clinical analytics to improve patient outcomes and build radiology practice value. 


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Topics: MIPS, Quality Payment Program, MIPS participation, radiology, QPP

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