With the publication of the Medicare Physician Fee Schedule (MPFS) Final Rule for 2019, which includes the Quality Payment Program (QPP) Final Rule, we can now review how radiologists can prepare to maximize their 2021 Medicare reimbursement through QPP participation in 2019.  The QPP includes both the Medicare Incentive-based Payment System (MIPS) and Alternative Payment Model (APM) tracks.  Since most radiology groups are currently participating in MIPS, we will focus on steps to take for successful participation in this program.

Changes for 2019 in the QPP Final Rule

Eligibility for Participation in MIPS

Eligible Clinicians (EC) can be exempted from MIPS participation if they meet any of the low-volume threshold criteria, which include:

• Having less than $90,000 in Medicare reimbursement, or
• Providing covered services to fewer than 200 Medicare beneficiaries.

In addition to these two existing exemption criteria, ECs can now be exempted from MIPS if they provide 200 or fewer covered services to Medicare beneficiaries. 

Alternatively, a new feature in 2019 will be the ability for an EC to “opt-in” to the MIPS program if he or she meets one or two, but not all three, of the low-volume threshold criteria.  The Centers for Medicare and Medicaid Services (CMS) believes that these additions strike a balance between providing relief to small practices and creating opportunities for those who wish to participate.

Category Values for Final Score

Here are the 2019 nominal category weights as compared with those for 2018:

The weight of the Quality Category can become 70% if a radiologist is exempted from the Promoting Interoperability category, and up to 85% if the individual clinician or group does not meet the minimum patient attribution thresholds for any Cost measures.  The reasons for category re-weighting are the same for 2019 as they were in 2018, including the non-patient facing and hospital-based exemptions that commonly apply to radiologists. 

The Small Practice Bonus is increased from 5 points to 6 points, and it will now be added to the Quality Category numerator rather than to the Final Score.  This could be a benefit to practices of 15 or fewer Eligible Clinicians (EC) that are struggling to maximize their Quality score. 

 
Payment Adjustments in 2021

Medicare payments will be adjusted in 2021 based on performance in reporting year 2019.  The Performance Threshold is increased from 15 points to 30 points.  This is the minimum score needed in order to avoid a payment penalty.  An Eligible Clinician (EC) who is scored on fewer than two performance categories will be assigned a Final Score of 30 points and the payment adjustment will be 0%.   For full participants, the payment adjustments will range from a 7% decrease to a 7% increase, modified by a scaling factor to achieve budget neutrality.  The Exceptional Performance Bonus threshold is increased from 70 points to 75 points.

Facility-Based Scoring

Facility Based Scoring is an entirely new option for 2019.  A physician or group practice that bills at least 75% of their Medicare services in a hospital setting (inpatient, outpatient or emergency department) will be eligible for Facility-Based Scoring under the hospital Value-Based Purchasing (VBP) program.  This means that the MIPS Quality and Cost scores will be assigned based on the VBP performance of the facility to which they are attributed, while the Promoting Interoperability and Improvement Activities categories would still have to be submitted by the practice. Facility-based scoring will only be applied if the clinician or group receives a higher combined Quality and Cost score from the VBP assessment than their MIPS submissions would achieve.

Performance Category Changes

Quality  

Practices may now submit data using multiple collection types, whereas previously a single collection type had to be selected.  The data collection options include Clinical Quality Measures (CQM), Electronic CQM (eCQM), Qualified Clinical Data Registry (QCDR) and Medicare Claims.  However, submission via claims will only be available to small practices (those with 15 or fewer EC’s).

Two quality measures relevant to radiology have been removed:

• #359 Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for CT Imaging.
• #363 Optimizing Patient Exposure to Ionizing Radiation: Search for Prior CT Studies Through a Secure, Authorized, Media-Free, Shared Archive.

Promoting Interoperability (previously ACI)

Use of the 2015 Certified EHR Technology Edition is now required, and accordingly there is no longer a bonus for using 2015 CEHRT. 

A new performance-based scoring methodology will be used for the Promoting Interoperability (PI) category that scores each measure based on the EC’s performance for that measure using the submission of a numerator or denominator, or a “yes or no” submission, where applicable.  This would eliminate the base, performance, and bonus scoring methodology.

Improvement Activities

6 new activities have been added to the inventory of Improvement Activities, 5 were modified and one was removed.  None of these modifications impact radiology practices, but there continue to be 7 activities that the use of R-SCAN[*] can fulfill.  The early adoption of a Clinical Decision Support (CDS) system continues to be a high-weighted activity.  There is no bonus available in the Promoting Interoperability category for using CEHRT to achieve of any Improvement Activities. 

Cost

The Cost Category will first be factored into the final score for 2018.  Eight (8) episode-based measures will be added to the list of Cost measures for 2019.  The case minimum for procedural episodes will be 10, with episodes attributed to each EC who renders a trigger service.  The minimum for acute inpatient medical condition episodes will be 20 cases, with episodes attributed to each EC who bills inpatient E&M codes during a trigger hospitalization under a Taxpayer Identification Number (TIN) that renders at least 30% of the inpatient E&M services during that hospitalization.

Successful Participation in 2019 for Radiology Practices

Practices that are participating in MIPS for 2018 are well on their way to achieving success in 2019 and they will only need to make some minor adjustments to accommodate the program changes described above.  Those practices that have been exempt from MIPS will have to evaluate whether they will continue to be exempt based on their volume of activity, or perhaps they might want to “opt-in” using this new rule if they feel that a positive payment adjustment could result from participation.  Another option to investigate is Facility Based Scoring, which could be advantageous to practices if the scores from their hospital are better than those that have been submitted by the practice.

Healthcare Administrative Partners recommends that practices understand the following points in the new final rule for 2019. 

Determination Periods

The Determination Period is used to evaluate whether ECs or groups fall into certain categories under MIPS.  These include:

• Low-volume status, which could exempt the EC or group from the MIPS program.
• Non-patient facing status, which could exempt the EC or group from the Promoting Interoperability (PI) category and change the requirements under the Improvement Activities (IA) category.
• Small Practice status, which provides a bonus under the Quality Category.
• Hospital-based or Ambulatory Surgery Center (ASC)-based status, which provides exemption from the Promoting Interoperability (PI) category.

The first determination period includes the twelve months that end on September 30 of the preceding year, so for 2019 this would be October 1, 2017 to September 30, 2018.  The second period includes the twelve months that end on September 30 of the measurement year, so for 2019 this would be October 1, 2018 to September 30, 2019.  Using two measurement periods helps to account for changes in practice patterns, and for ECs who change employment.

The Complex Patient Bonus, which provides a 5-point bonus to ECs who treat medically complex patients, uses the second Determination Period to calculate the average Hierarchical Condition Category (HCC) risk scores and the proportion of beneficiaries with dual-eligible status.

Be Aware of Performance Thresholds

MIPS participants must attain a final score of at least 30 points in the 2019 measurement year to avoid a payment penalty.  When fewer than two performance categories are reported, the EC or group will be assigned the score of 30 points and will receive a 0% adjustment.

On the other end of the spectrum, a final score of at least 75 points will earn an additional upward payment adjustment for Exceptional Performance.  The actual amount of the adjustment will not be known until all of the scoring has been completed some time in 2020, but the maximum adjustment will be 7% of eligible Medicare payments in 2021. 

Adjustment of Quality Measures

The Quality Performance Category usually becomes the area of greatest focus for radiologists, who are often exempted from the PI category.  Quality can account for up to 85% of the final score, so it is important to understand the measures available for radiology practices.  For 2019, two measures were eliminated as described above.  In addition, Measure #364 “Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines” was revised as follows:

• The denominator now applies to patients age 35 and older rather than age 18 and older
• The denominator now excludes heavy tobacco smokers
• The denominator exceptions now include medical reasons
• The numerator now includes a recommended interval and modality for follow-up

Our article describes one way pulmonary nodules can be tracked in your practice.

 
Understand the Cost Category

Our article earlier this year gave an overview of how the Cost Category works.  The critical focus for radiologists will be the Medicare Spending Per Beneficiary (MSPB) measure, as other measures will likely be out of scope.  Accordingly, practices can review their MSPB patient attribution in reports provided by CMS to determine if they will be subject to the Cost Category or not.  If no cost measures are attributed to a practice, then a Cost Performance score will not be calculated and the score will be re-weighted to Quality.  There is no submission required by ECs for the Cost Category as CMS makes determinations based on year-end claims.

Conclusion

Successful performance in MIPS begins with an understanding of the practice’s status, including the status of each individual EC in the group, based on the revised criteria presented here and with an awareness that circumstances like the patient-facing percentage can change from year to year.  If the practice is participating in MIPS during 2018, review which measures and other parameters are changing and adjust workflows accordingly. Virtual groups or facility-based scoring might be viable options for some practices. 

With this basic information decisions can be made about where efforts should be focused for 2019.  And of course, stay in touch with regulatory developments and suggestions for success that we cover here in our blog on a regular basis. 

Richard Morris is the Director of Value-Based Strategy at Healthcare Administrative Partners.

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[*] R-SCAN is a product of The American College of Radiology.