Knowing the Score: MIPS

Knowing the Score: MIPS

EDITOR’S NOTE: Medicare’s legacy quality reporting programs were consolidated and streamlined into the Merit-Based Incentive Payment System, known as “MIPS.” 

The Merit-Based Incentive Payment System (MIPS) uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty, or no payment adjustments. 

If a physician bills more than $90,000 for Part B-covered professional services and they see more than 200 Part B patients, and has provided more than 200 covered professional services to those patients, the physician must participate in the MIPS program. It’s essential for all eligible clinicians to report in order to prevent a 9-percent downward adjustment for all Medicare Part B claims paid two years from the reporting year.  

The MIPS performance year begins Jan. 1, ends on Dec. 31 each year. If you’re eligible for MIPS, you must report data collected during the calendar year by March 31 of the following calendar year. Payment adjustments, based on the data you submit for services provided, are applied to Medicare Part B claims during Jan. 1 to Dec. 31 of the year following data submission. For example, if you collect data between Jan. 1 and Dec. 31, 2023 (i.e., the performance year), you must report your data by March 31, 2024, and you’ll receive a MIPS payment adjustment between Jan. 1 and Dec. 31, 2025 (i.e., the payment year). General reporting requirements are as follows:

  • You’ll need to submit collected data for at least six quality measures (including one outcome measure or high-priority measure in the absence of an applicable outcome measure), or a complete specialty measure set.
  • You’ll need to report performance data for at least 75 percent of the denominator eligible cases for each quality measure (data completeness).
  • You can submit measures from different collection types to fulfill the requirement to report data for at least six quality measures.

On Nov. 2, 2023, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Medicare Physician Fee Schedule (PFS) Final Rule, which includes updates to the Quality Payment Program (QPP).

The below segment summarizes a few of the key policy changes affecting the traditional MIPS program and MIPS Value Pathways (MVPs). A provider’s annual MIPS score of up to 100 points is calculated based on four categories of performance:

  1. Quality: Based on quality measures created by CMS. Providers choose six measures of performance that align with their care initiatives. This accounts for 30 percent weight or 30 MIPS points maximum.
  2. Improvement activities include activities that improve care processes, enhance patient engagement in care, and increase access to care. This accounts for 15 percent weight, or 15 MIPS points maximum.
  3. Resource use (cost): the total cost of care calculated using Medicare claims. This accounts for 30 percent weight, or 30 MIPS points maximum.  
  4. Promoting Interoperability: Providers earn points by demonstrating that they proactively share information with other providers or patients. Examples include sharing test results and providing visit summaries to patients. This accounts for 25 percent weight, or 25 MIPS points maximum.
Final Threshold for 2024 Will Remain at 75 points

The 2024 MIPS performance year begins on Jan. 1, 2024. Physician performance across the four MIPS performance categories in 2024 – Quality, Cost, Promoting Interoperability, and Improvement Activities – will determine payment adjustments to Medicare Part B claims in 2026. Final MIPS scores are compared to the performance threshold to calculate the MIPS payment adjustment. The table below breaks down final MIPS scores and their associated payment adjustments, based on the performance threshold.

2024 Performance Period
2024 Final MIPS Score 2026 MIPS Adjustment
0.0-18.75Negative 9%
18.76-74.99Negative MIPS payment adjustment greater than negative 9% and less than 0% on a linear sliding scale
75.00% adjustment
75.01-100Positive MIPS payment adjustment greater than 0% on a linear sliding scale. The linear sliding scale ranges from 0 to 9% for scores from 75.00 to 100.00. This sliding scale is multiplied by a scaling factor greater than zero but not exceeding 3.0 to preserve budget neutrality.
2024 MIPS Value Pathways (MVPs) Update

CMS continues to signal its intent that MVPs are the future of MIPS. To further this vision, CMS finalized five new MVPs for the 2024 performance year, along with revisions to the previously finalized MVPs.

Specifically, CMS finalized its proposal to consolidate the previously finalized MVPs, Promoting Wellness MVP and Optimizing Chronic Disease Management MVP, into a single primary-care MVP. The five new MVPs are the following: 

  1. Focusing on Women’s Health; 
  2. Quality Care for the Treatment of Ear, Nose, and Throat Disorders; 
  3. Prevention and Treatment of Infectious Disorders including Hepatitis C and HIV;
  4. Quality Care in Mental Health and Substance Use Disorders; and 
  5. Rehabilitative Support for Musculoskeletal Care.

There will be a total of 16 MVPs available for reporting in the 2024 performance period.

2024 Quality Measure Inventory Changes

There are 198 quality measures for the 2024 performance period, which reflect the following:

  • Eleven new quality measures;
  • Removal of 11 quality measures;
  • Partial removal of three measures (retained for MVP use only); and
  • Substantive changes to 59 existing quality measures.

A list of new 2024 quality measures, along with their collection types, are outlined below:

2024 Higher Data Completeness Criteria for Quality Measures

Clinicians must meet “data completeness” when reporting quality measures to ensure that the data submitted is sufficient to assess quality performance. CMS previously finalized a 75-percent data completeness threshold for the 2024 and 2025 performance periods (up from 70 percent in 2023) for electronic Clinical Quality Measures (eCQMs), MIPS CQMs, Medicare Part B claims measures and QCDR measures. This means that quality measures must be reported on a minimum of 75 percent of eligible instances for the entire year.

2024 Improvement Activities Category Updates

There are 106 improvement activities in the MIPS inventory for 2024, including five new activities. New improvement activities include:

  • Improving Practice Capacity for HIM (Health Information Management) Prevention Services;
  • Practice-Wide Improvement in MIPS Value Pathways;
  • Use of Decision Support to Improve Adherence to Cervical Cancer Screening and Management;
  • Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women; and
  • Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults.

So, whether you are new to MIPS or seasoned, it is crucial to pay close attention to the changes in 2024.

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Leigh Poland, RHIA, CCS

With more than 20 years of coding experience, Leigh Poland is dedicated to providing education globally to ensure medical coders are equipped to do their job accurately and with excellence. As the vice president of coding services at AGS Health, Leigh leads the company's internal training and continuing education programs.

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