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A Comprehensive Overview of MIPS for Pathology: Closing Out 2019 & Moving Forward with 2020

Results were recently published from the 2019 MIPS program, illustrating yet another impact of the COVID pandemic on healthcare providers and their practices.  

Originally for performance year (PY) 2019, a participating provider/group had to meet the performance threshold of 30 points to avoid a negative payment adjustment and be eligible for a positive payment adjustment.  Those scoring at least 75 points would be additionally eligible for the exceptional performance payment adjustment, additional bonus money that comes from a separate pool of money in the MIPS program.

In response to the COVID-19 pandemic, CMS automatically extended its Extreme and Uncontrollable Circumstances policy to clinicians reporting as Individuals in PY2019.  This flexibility meant that providers who did not submit any data, or who only submitted data in one performance category, automatically received a neutral payment adjustment, thus avoiding a penalty. Those participants reporting as Groups were able to submit applications for this hardship policy that, if approved, essentially provided the same neutral payment adjustment for the performance year.

Due to the budget neutrality required of the MIPS program that is not allowed to be impacted by implementing the Extreme and Uncontrollable policy, participating clinicians/groups now had to score 75 points in PY2019 to earn a positive payment adjustment, which topped-out at 1.79%.  Discouraging news for many participants – especially those that couldn’t reach 75 points -  but for some, the new Facility Based Measurement came to the rescue, lifting scores for a second chance at a piece of the pie.  

Here’s how it works:
Physicians who are designated as facility-based and working primarily in hospitals were eligible to have their Quality and Cost category scores based on their hospital’s performance under the Hospital Value-based Purchasing (VBP) Program which is linked to the Inpatient Prospective Payment System.

•    First, physicians/groups were attributed by CMS to the facility where they service the most Medicare patients; that facility had to have a fiscal year 2020 Hospital Value-Based Purchasing score (VBP)
•    Under the facility based measurement, the facility's performance score could replace the scores for the physician's/group's reported quality data and cost score (if applicable), if higher than the physician’s/group’s own data
•    Finally, CMS automatically bumped the facility’s VBP score against the score of the data submitted by the participating provider/group and used the higher of the two scores for the final calculation of the PY2019 results.

NOTE:  Providers that are part of an Alternative Payment Model (APM) or Advanced Alternative Payment Model (AAPM) should check with the program directors at their facilities for 2019 results detail and direction on 2020 participation.

Now let’s look at the current 2020 requirements of the MIPS program specifically as they pertain to pathologists, starting with the basics.

Performance Year 2019 Policy

Performance Year 2020 Policy

Maximum negative payment adjustment is -7%

 

Maximum negative payment adjustment is -9%

  • Performance threshold is 30 points
  • Exceptional Performance threshold is 75 points

 

  • Performance threshold is 45 points
  • Exceptional Performance threshold is 85 points

Facility-Based Measurement considered in final score if applicable

 

No Change

  • Quality category: 70% (includes reweighting of the Promoting Interoperability category from which providers designated as hospital based are exempt)
  • Cost category:  15% if applicable (if not applicable, this category is also reweighted to the Quality category)
  • Improvement Activities:  15%

 

No Change

Again this year, the vast majority of pathologists will report on two categories:  Quality and Improvement Activities.  Note that this year, 45 points have to be earned to avoid a negative payment adjustment.  This is important to consider because, compared to other specialties, Pathology has a small number of applicable measures to report on for the Quality category and they all have been designated as “Topped-Out.”  

•    Topped-Out means a measure’s average scores have been consistently high with a distinct lack of variability.  When a measure is designated as Topped-Out it follows the CMS process to eventually be deleted from the program.  Part of this process includes capping the maximum points that can be earned for the measure at 7. 

 

Measure ID

 

Measure Description

 

Topped-Out PY2020

Y/N

7 Point Cap PY2020

Y/N

249

Barrett’s Esophagus

 

Yes

Yes

250

Radical Prostatectomy

 

Yes

Yes

395

Lung Cancer – Biopsy/Cytology Specimens

 

Yes

Yes

396

Lung Cancer – Resection Specimens

 

Yes

Yes

397

Melanoma Reporting

 

Yes

Yes

440

Skin Cancer:  Biopsy Reporting Time

 

Yes

Yes

Prior to being capped at 7 points, these measures each qualified for full 10-point scoring for a total of 60 possible points.  Now capped at 7 points, they are worth a collective total of 42 possible points.

Measure 440 was the only measure with a notable change to its specifications this year.  Previously specific to Basal and Squamous Cell Cutaneous Cancer cases, it now also includes Melanoma Cutaneous cases.  See the link under Resources at the end of this document to review the specs of the 2020 MIPS quality measures.

The Improvement Activities (IA) performance category gauges your participation in activities that lead to improved clinical practices.  This category has over 100 activities from which program participants can choose for reporting as applicable to their practices.  As in previous years of the program each reported activity must be performed for a minimum of 90 continuous days during 2020.

•    New in 2020:  for Group reporting, 50% of the group has to perform the reported activity but they do not have to share the same continuous 90-day period.

Reporting is handled via attestation to the MIPS program.  Once you’ve identified the IAs that apply to your practice, APS will complete your attestation(s) on your behalf.  See the link under Resources at the end of this document to review all 2020 Improvement Activities.

•    Take note:   Clinicians are expected to retain all supporting documentation for each attested activity for 10 years  
•    APS strongly encourages clinicians to review CMS’ Validation Criteria for each of their attested activities to ensure they have compiled the necessary supporting documentation.  See the link under Resources at the end of this document to review this information.

Again this year, maximum number of points that can be earned for this category is 40.  Activities are worth either 10 or 20 points with these points doubled for clinicians/groups designated by CMS as:
•    Small Practice (15 or fewer clinicians)
•    Non-patient facing
•    Rural
•    Health Professional Shortage Area (HPSA)

Groups with more than 15 clinicians that are not in a rural area or HPSA will need to report:

 

 

2 high-weighted activities OR

1 high-weighted activity and 2 medium-weighted activities OR

4 medium-weighted activities

Groups with 15 or fewer clinicians, non-patient facing clinicians, and/or clinicians located in a rural area or HPSA will need to report:

 

1 high-weighted activity OR

2 medium-weighted activities

 

CMS created a new high-weighted IA this year in response to the pandemic: “COVID-19 Clinical Data Reporting with or without Clinical Trial.”  To earn credit participants must:  

•    Participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study OR 
•    Participate in the care of COVID-19 patients and simultaneously submit relevant clinical data to a clinical data registry for ongoing or future COVID-19 research

To get started, clinicians should check their eligibility for participation in 2020 MIPS by entering their NPIs at the following link:  https://qpp.cms.gov/participation-lookup

•    There will be more than one practice listed if the provider renders services under more than one tax ID – be sure to check status for each practice
•    Note any that reference APM status and follow-up with the APM entity at the facility for further direction
•    Notify APS of APM status 

Document Resources

Select 2020 Clinical Quality Measure Specifications and Supporting Documents to review current specs of the 2020 MIPS measures at the following link:
https://qpp.cms.gov/mips/explore-measures?tab=qualityMeasures&py=2020#measures

Select 2020 Improvement Activities Inventory on page 12 at the following link:
https://qpp-cm-prod-content.s3.amazonaws.com/uploads/818/2020%20Improvement%20Activities%20Quick%20Start%20Guide.pdf

Select 2020 Improvement Activities Data Validation Criteria.pdf at the following link: https://qpp.cms.gov/mips/improvement-activities   
 

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