The Merit-based Incentive Payment System: 2022
The Centers for Medicare and Medicaid Services (CMS) released the Proposed Rule for the 2022 Medicare Physician Fee Schedule on July 13th, 2021, which included proposed changes to the Quality Payment Program. The focus of this article is the changes to the Merit-based incentive Payment System (MIPS) and the potential impact on eligible clinicians.
Category Weightings
In 2022, the Performance category weightings can no longer be adjusted by CMS and the weightings for 2022 are illustrated in Exhibit A.[1] Notice the cost category is now equally weighted with the quality category.
Exhibit A: 2022 MIPS Performance Category Weightings
[1] The Proposed Rule updates the reweighting for small practices when promoting interoperability is reweighted as follows: quality (40%), cost (30%) and improvement activities (30%). If Cost is also not applicable the weighting is as follows: quality (50%) IA (50%).
Penalty Threshold
Likewise, in 2022 CMS is required to establish the penalty threshold at either the historical mean or median of the final MIPS scores for all eligible clinicians. Groups must score higher than the penalty threshold to avoid a negative payment adjustment.
The penalty threshold is proposed to increase from 60 MIPS points in 2021 to 75 MIPS points in 2022. [2] The exceptional performance threshold is proposed to increase from 85 MIPS points in 2021 to 89 MIPS points in 2022. 2022 is the last performance year additional funding will be available to exceptional MIPS performers.
[2] 75 points represents the mean final score from the 2017 performance year. CMS chose to use 2017, because it resulted in the lowest possible penalty threshold.
Quality Performance Category
Notable changes are proposed to the quality performance category, which are anticipated to drop an average radiology group’s MIPS score by 10 to 15+ points.
These proposed changes include:
- Measures with a benchmark: Remove the 3-point floor, making the available range of points 1 to 10 (instead of 3 to 10).
- Measures without a benchmark: Remove the 3-point floor and receive 0 points if a retroactive benchmark is not assigned and the measure is not new[3].
- Measures that do not meet the case minimum of 20 eligible encounters: Remove 3-point floor and receive 0 points.[4]
- New Measures without a benchmark[5]: Establish a 5-point floor (earn 5 instead of 3 points).
- New Measures with a benchmark: Establish a 5-point floor (earn 5 to 10 points).
- Eliminate bonus points for end-to-end electronic reporting and the reporting of additional high priority and outcome measures beyond the required measures.
- Removal of the following quality measures commonly used by radiology groups:
- 195: Stenosis Measurement in Carotid Imaging Reports
- 225: Reminder System for Screening Mammograms
- 21: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin
- 23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
[3] Excepting small practices, defined as = 15 clinicians, who would continue to earn 3 points.
[4] Excepting small practices, defined as = 15 clinicians, who would continue to earn 3 points.
[5] New measure defined as any measure in its first or second year of the MIPS program.
No Proposed Change Sections
There are no proposed changes to the cost, improvement activities, and promoting interoperability performance categories that will significantly impact radiology practices.
However, the proposed changes to the quality performance category, will have a profound impact on radiology practices, particularly those who do not report their MIPS quality performance via a Qualified Clinical Data Registry (QCDR) [ex: use claims reporting or report through a Qualified Registry (QR)].
Providers who do not report MIPS data through a QCDR are limited to reporting only national Measures, which are numerical (for example 195, 225, 145, etc.). Many of the existing national MIPS measures for Radiology are topped out and devalued, or in some cases even deleted; and there are no new national measures to take their place. This leaves a radiology practice in a position where it will be difficult to avoid a penalty in 2022, especially if they are just reporting national quality measures.
Case Study:
Radiology Associates reported on the following 10 measures in 2021:
- 21: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin
- 23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
- 76: Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
- 145: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
- 147: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
- 195: Stenosis Measurement in Carotid Imaging Reports
- 225: Reminder System for Screening Mammograms
- 405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions
- 406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
- 436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Their performance rates, equivalent points earned, and high priority bonus points awarded are presented in Exhibit B.
Exhibit B: Radiology Associates 2021 MIPS Performance
Exhibit C shows the projected total MIPS score, based on the performance category weightings[6] for 2021.
Exhibit C: Projected MIPS Score for 2021
[6] Promoting Interoperability does not apply to this practice and has been reweighted to quality.
The performance threshold to avoid a penalty in 2021 is 60 total MIPS points, so Radiology Associates will earn a positive payment adjustment for the 2021 performance year, to be realized on its claims in 2023.
Radiology Associates has been reporting their MIPS measures through a qualified registry and has chosen to not change course in 2022. The impact of this decision is illustrated in Exhibit D.
Exhibit D: Projected 2022 MIPS Performance
Notable Changes to Score:
- Loss of High-Priority Bonus points (-6 quality points)
- Loss of measures 21, 23, 195, 225 (-15 quality points)
- Loss of 3-point floor (-2 points for low performance on measure 145, 147 & -3 points for measure 406 that has
- Gained points for 405, which is assumed to achieve a benchmark (+7 quality points). Note, measure 405 will earn this group 0 points if it does not achieve a benchmark, because of the removal of the 3-point floor on non-new measures with no benchmarks.
The forecast, based on the 2022 performance category weightings, is presented in Exhibit E and Radiology Associates can expect to earn a negative payment adjustment since their total MIPS score of 67[7] does not meet the performance threshold of 75.
Exhibit E: 2022 Forecast
[7] The total MIPS score of 67 will be lower if measure 405 does not receive a published benchmark. This forecast does not consider the patient complexity bonus, which could be 0 to 10 points in 2022. The methodology for determining eligibility for the patient complexity bonus is also proposed to change to make qualifying for the bonus more difficult.
How To Prepare
- Measure selection is critical in 2022. Radiology groups need to report on as many full-value measures as they can to boost their MIPS score. This means choosing measures that are not topped-out and have the potential of earning 10 points when performance is strong. They can do this in one of two ways:
- 1) Report their 2022 quality performance through a QCDR and report on QCDR quality measures available through their QCDR (most QCDR measures provide the potential to earn up 10 points if performed well). Remember, reporting through a QCDR is different from a QR, because QCDRs can host “non-MIPS” measures that have been approved by CMS, whereas QRs are limited to offering only national measures.
and/or
- 2) Report additional national measures that are not devalued. This is possible if the practice provides Interventional Radiology services where measures, such as measure 047 (Care Plan) or 110 (influenza immunization) are applicable. Or if the practice provides services in other specialties that have more full-value measures available.
- 2) Report additional national measures that are not devalued. This is possible if the practice provides Interventional Radiology services where measures, such as measure 047 (Care Plan) or 110 (influenza immunization) are applicable. Or if the practice provides services in other specialties that have more full-value measures available.
- Continue to perfect performance on existing measures. With so many radiology measures being topped out, even a few missed encounters on a measure can result in a sizable reduction in points earned. For instance, in the above case study for Radiology Associates, an increase in performance on measure 436 from 98.2% to 100% will gain the practice 4 more quality points (move from 3 to 7 points).
- Ensure you understand the cost measures that are applicable to your group, if any. If the cost category of MIPS is applicable to your group (typically it is if you provide IR services), then become familiar with the specific services you are providing and the types of patients who are having an impact on your cost score. Then focus on reducing complications and unnecessary costs incurred by these types of patients. A good place to start is to review the 2019 cost data in your QPP account to identify patients who contributed to your cost score.
Summary
The bottom line is the MIPS program, as proposed, becomes significantly more difficult in 2022. Groups who have historically scored in the “exceptional performance” zone can find themselves with a score in the penalty zone in 2022 and beyond, unless they anticipate these programmatic changes and plan accordingly. It is imperative clinicians understand how these changes will impact their performance and what strategies they can undertake to mitigate any negative impact. There is a silver lining; with the anticipation of more groups being penalized in 2022, those who keep their MIPS score high will be more handsomely rewarded than in years past[8].
[8] CMS estimates in the 2022 Proposed Rule that MIPS scores above 89 points (the exceptional performance threshold) could yield positive payment adjustments of 4 to 14%.
MSN QCDR
If you are interested in learning more about the MSN QCDR or enhanced MIPS consulting services offered through the MIPit program, please contact:
Barbara F. Rubel MBA, FRBMA
Senior VP, Marketing & Client Services
Immediate Past President, FRBMA
904-657-2038 (Office) | 770-823-3597 (Cell)
or
Marissa S. Pearce, MHS
Executive Director of Quality Payment Programs
MSN QCDR | MIPit Consulting Services
(p) 301-908-0358
Barbara Rubel MBA, FRBMA Senior Vice President, Marketing & Client Services
Barbara has been a leader with MSN Client Services since 1998. Her extensive background in strategic planning, market research, healthcare marketing and managed care negotiations provides a wealth of information to support MSN Clients.
Barbara has also been highly involved in industry organizations, serving as President of the Radiology Business Management Association (RBMA), the Georgia RBMA, and the Florida RBMA. In addition, she chaired the influential RBMA Federal Affairs Committee and the RBMA Technology Task force and was a member of the RBMA Data Committee. Her work on behalf of radiology has earned her the RBMA Special Recognition Award (2010), the RBMA Global Achievement Award (2013), and she is a Fellow of the RBMA.
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