After multiple educational CMS calls during 2017, the changes for 2018 Merit-based Incentive Payment System (MIPS) are not new news, but you need to know what MIPS 2018 changes matter and why.

MIPS for 2018

After multiple educational CMS calls during 2017, the changes for 2018 Merit-based Incentive Payment System (MIPS) are not new news, but you need to know what MIPS 2018 changes matter and why. The release of the final rule on November 2nd was even a bit anticlimactic, but in case you missed any of this, here are some helpful links to take you directly to the source:

If the Medicare statutes are too onerous or voluminous for you, and a quick recap is desired, below are significant highlights for MIPS 2018:

Category Changes

The Cost category will be counted in 2018 despite no value in 2017 scoring. This means all 4 MIPS categories will count for something in 2018, with the highest point category remaining the Quality.  On a 100-point scale, following is the breakdown of points for MIPS 2018.

  • 50% Quality (Legacy: Physician Quality Reporting System Program (PQRS))
  • 10% Cost (Legacy: Value-Based Modifier program (VBM))
  • 25% Advancing Care Information (ACI; Legacy: Meaningful Use program (MU))
  • 15% Improvement Activities (IA; New category, Clinical Practice Improvement Activity)

Remember, MIPS is a new program replacing or rolling up historic (legacy) incentive programs. The specific requirements and weights/points for each category demonstrate their value in the overall program. If you need a refresher on MIPS or are just starting to learn about this program, have a look here for an overview.

Eligibility Changes

Eligible Clinicians (ECs, known previously as Eligible Providers (EP)) have remained the same but the exclusion threshold has changed.  In 2018, if a provider sees fewer than 200 Medicare patients or individually bills (i.e., charges) less than $90,000 to Medicare, s/he is exempt. There are nuances so it’s best and safest to ALWAYS check eligibility before getting started. Enter your NPI at this link to know whether your or another NPI is deemed eligible.

Virtual Groups

Virtual groups are also an option for MIPS 2018 and might be helpful for solo or small practice (10 or less) providers who think their performance could benefit from partnering with other similar providers. For instance, small or solo practice providers can partner with other similar providers to share best practices and optimize care vs. only working with the typically smaller pool of patients in a vacuum of care. Skeptics and optimists abound, but if you want more information, check out the virtual group toolkit section which is the last bullet just before the Advanced APM section.

Threshold and Payment Adjustment Changes.

For the Quality category in 2018 six (6) quality measures must be reported for the full year. No more test pace or 90 day options exist.  Further, if you don’t meet data completeness for this category, each measure only earns 1 point, rather than 3 points. What is data completeness?  For each measure, it means reporting on greater than 50% of all your patients for that measure and that 50% has to be AT LEAST 20 patients to be scored against the benchmark.

Questionable Quality Measures

There are certain Quality Measures you may want to avoid as CMS has determined them to be “topped out” vs. other options. Certainly, there are nuances to the discussion, but essentially these measures don’t afford maximum points and won’t optimize your score. As such, may make sense to choose other measures expected to have a longer shelf-life with a better opportunity for elevated scoring.

Here are some examples:

  • 21: Perioperative Care: Selection of Prophylactic Antibiotic-First or Second-Generation Cephalosporin
  • 23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
  • 52: Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy
  • 224: Melanoma: Overutilization of Imaging Studies in Melanoma
  • 262: Image Confirmation of Successful Excision of Image-Localized Breast Lesion
  • 359: Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description

If you want to learn more about the granular aspects of how and why a measure becomes “topped out” and what that means for you, details can be found here on page 9.

Minimum Threshold to Avoid Negative Adjustment In 2018 a minimum of 15 points must be earned across all MIPS’ measure categories to avoid a -5% payment adjustment for 2020. Earn 15 points and avoid downward (negative) adjustment. If you earn 16-69 points you will be neutral or see a potential (albeit small) upward or positive adjustment. Earn over 70 points and opportunity exists for an exceptional bonus although the exact amount is always “TBD.” So again, 15 points is the magic number to avoid the -5% payment adjustment.

While program complexity expands it is still pretty easy to avoid negative adjustment by achieving 15 points. Here are some options to make this happen:

  1. Report all required Improvement Activities (IA).
  2. Meet the Advancing Care Information (ACI) base score and submit one (1) Quality measure that meets data completeness.
  3. Meet the Advancing Care Information (ACI) base score by reporting the five (5) base measures and submit one (1) medium-weighted Improvement Activity.
  4. Submit six (6) Quality measures that meet data completeness criteria.


What do these changes really mean for you and your practice? The answer depends on your goal. If you just want to avoid negative adjustment in 2020, earning the 15 points requires just a little advanced planning. If bonus is the goal, some thought and strategy are necessary to maximize performance, perceived or actual. If bonus and upholding the “spirit of the program” to improve quality of care are mutually inclusive, taking the final weeks of 2017 to prepare to optimize measure performance is essential. Do you have an easy data capture options with a meaningful dashboard to guide you and/or your colleagues? Do you have a QPP consultant and/or registry partner to answer questions or assist with navigating the abyss of CMS program information?

It is possible to balance the spirit of the MIPS 2018 program while maximizing the strategic game with integrity.  In the end, you should be able to earn bonus, improve patient outcomes, and see care quality elevate… the trifecta of the QPP. This three-fold win requires getting started early, strategically selecting measures, and making adjustments to your quality of care throughout the reporting year. Doing this will almost certainly equate to higher points and eventually more money in your pocket!

Regardless, of your objectives, taking a little time now to prepare for MIPS 2018 will result in less stress and more optimal performance for you, your practice, and your patients.

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