The year 2019 marks the third reporting period under the Medicare Incentive-based Payment System (MIPS). Radiology groups’ performance this year will determine their positive or negative Medicare fee schedule adjustment for payments in 2021, just as this year’s Medicare payment adjustment was determined by performance in 2017.
Quality Performance Measures
The MIPS program is revised annually by CMS, the Centers for Medicare and Medicaid Services, and practices have to be aware of the changes so they can optimize their performance. One of the annual adjustments is to move the bar a bit higher in order for physicians to meet quality objectives. When a quality measure’s performance reaches a median of 95% or higher, it is designated as being “topped out” – and after 3 consecutive years of being topped out, it is dropped from the list of available measures. For 2019, the following measures were eliminated:
For Diagnostic Radiology:
- #359 Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging
- #363 Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive
For Radiation Oncology:
- #99 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
- #100 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
- #156 Oncology: Radiation Dose Limits to Normal Tissues
No measures related to Interventional Radiology were removed for 2019.
The task for radiology practices is to find replacements for these removed measures that will allow them to reach the minimum of 6 measures required for full reporting under the MIPS Quality Performance category. HAP has found that the following measures are generally attainable by diagnostic radiology practices:
| Measure ID | Measure Name | NQS Domain | Measure Type | |
| 145 |
|
Patient Safety | Process | |
| 146 | Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | Efficiency and Cost Reduction | Process | |
| 225 | Radiology: Reminder System for Screening Mammograms | Communication and Care Coordination | Structure | |
| 361 | Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | Patient Safety | Structure | |
| 405 | Appropriate Follow-up Imaging for Incidental Abdominal Lesions | Effective Clinical Care | Process | |
| 406 | Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | Effective Clinical Care | Process | |
| 436 | Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | Effective Clinical Care | Process |
All of these (except #436) are High Priority measures, the submission of which will earn bonus points for the practice.
Understanding Payment Adjustments
Practices that received the highest possible MIPS Final Score in 2017 earned a 1.88% positive adjustment to the Medicare fee schedule for payments in 2019. Does this mean you will see at least 1.88% more Medicare revenue than you did in 2018? The answer is different for each and every practice, but overall it is “probably not”. Here’s why.
There are many variables that go into the payment a practice receives for services to Medicare patients. For one thing, the fee schedule received an overall increase of 0.11% due to the conversion factor adjustment. Then, individual procedures were increased or decreased as we described in our recent article, Understanding the Valuation Changes in the Final Medicare Fee Schedule for 2019. Finally, we have the adjustments for MIPS performance, either positive or negative, along with now-routine Sequestration Adjustment. The combination of all these factors will determine the final increase or decrease in total Medicare revenue for the practice.
With regard to the MIPS adjustment, however, we can illustrate how the reimbursement for a given procedure will be calculated. After determining the procedure’s allowed amount from the Medicare Fee Schedule, and calculating the patient’s deductible and coinsurance, the following adjustments will be applied:
| Remittance Advice (RA) Code | Description | Interpretation | |
| CO-144 |
|
Positive MIPS adjustment | |
| CO-237 | Legislative/Regulatory Penalty | Negative MIPS adjustment | |
| CO-253 | Sequestration – Reduction in federal spending | 2% mandatory reduction in Medicare payments |
It’s important to realize that these adjustments come after subtraction of the patient’s deductible (if any) and the patient’s 20% co-insurance amount from the fee schedule. This example uses a sample fee schedule amount of $1,000 and a 1.88% MIPS positive adjustment:
| Last year | This year | |||
| Fee schedule amount | $1,000.00 | $1,000.00 | ||
|
- | - | ||
| Sub-total | $1,000.00 | $1,000.00 | ||
| Coinsurance | 20% | $(200.00) | $(200.00) | |
| Sub-total | $800.00 | $800.00 | ||
| MIPS incentive added | 1.88% | $15.04 | ||
| Sub-total | $800.00 | $815.04 | ||
| Sequestration deducted | 2.00% | $(16.00) | $(16.30) | |
| Net amount paid by Medicare | $784.00 | $798.74 | ||
| Increase this year | $14.74 or 1.88% | |||
The practice does actually receive 1.88% more from Medicare this year than it would have for the same fee schedule amount last year. However, the MIPS adjustment and the sequestration reduction do not apply to the patient’s responsibility for the deductible or coinsurance. Therefore, the total reimbursement for the procedure will be increased only 1.50% after all is said and done, as we see by continuing the example below:
| Last year | This year | |
| Net amount paid by Medicare | $784.00 | $798.74 |
| Coinsurance paid by patient | $200.00 | $200.00 |
| Total received by the practice | $984.00 | $998.74 |
| Increase this year | $14.74 or 1.50% |
Conclusion
It’s important to keep on top of the annual changes to the Medicare Quality Payment Program (QPP) of which MIPS is one part. The reward for optimizing your practice’s participation and the penalty for not participating will vary over time, becoming larger in both directions. Once you have done everything possible to maximize your score, it then becomes necessary to understand what that means in terms of actual payment two years later. Stay connected to all of the changes in the Medicare program by subscribing to this blog.
Richard Morris is the Director of Value-Based Strategy at Healthcare Administrative Partners.
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