MIPS 2022: The Elusive Cost Category
As anyone who digs into the Cost category of the Merit-based Incentive Payment System will find, the methodology for calculating the score is both complex and elusive. If it were possible to watch someone’s head actually spin, it’s the Cost category that might be to blame.
With this single category now accounting for its full policy maximum of 30 out of 100 points, it’s time we distill its complexity. Cost has three main measure types under which to score clinicians, each with its own set of requirements. Below, we break each down to offer a bit more clarity. There are a total of 25 Cost measures available for the performance year 2022.
Total Per Capita Cost (TPCC)
Total Per Capita Cost (TPCC) measures the overall cost of care provided to Medicare patients, with a focus on the primary care they received.
Specifically, this encompasses all Medicare Part A and Part B costs for patients attributed to the individual clinician with the most allowed charges for E&M services other than the in-patient hospital, emergency department, and skilled nursing visits during the performance period. This means you may and likely will be judged on additional costs NOT delivered within the four walls of your practice. Understanding if a patient will be attributed to your practice, and how many patients overall may be attributed can be key to ensuring a good score on this Cost measure. For CMS to calculate a score on this measure, only 20 patients need to be attributed to a physician or group.
Medicare Spending Per Beneficiary (MSPB)
Medicare Spending Per Beneficiary (MSPB) measures the cost of services related to a hospital stay provided to Medicare patients.
This measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (hereafter referred to as the “episode”), which comprises the period immediately before, during, and following the patient’s hospital stay. An episode includes Medicare Part A and Part B claims with a start date between 3 days before a hospital admission (also known as the “index admission” for the episode) through 30 days after hospital discharge, excluding a defined list of services that are unlikely to be influenced by the clinician’s care decisions and are, thus, considered unrelated to the index admission. In all supplemental documentation, the term “cost” generally means the standardized Medicare allowed amount.
The numerator for the MSPB Clinician measure is the sum of the ratio of payment-standardized observed to expected episode costs for all episodes attributed to the clinician group, as identified by a unique Medicare Taxpayer Identification Number (TIN), or to the clinician, as identified by a unique TIN and National Provider Identifier pair (TIN-NPI). The sum is then multiplied by the national average payment-standardized observed episode cost to generate a dollar figure.
The denominator for the MSPB Clinician measure is the total number of episodes attributed to a clinician or clinician group.
Episode Measures
The Episode measures track costs for items and services provided during 23 procedural and condition-based episodes of care for Medicare patients.
The complete list of episode measures can be seen below and includes 5 new and wide-reaching options to be scored in 2022.
The list includes one measure on Melanoma Resection (10 episode case minimum) and one on Diabetes (20 episode case minimum). These two measures could easily impact dermatology and ophthalmology practices and physicians. This means while you may not have received a Cost score on episodes in the past, or avoided being scored in this category entirely, all 30 category points could hinge on just one or two of these measures in 2022.
Procedural Episode-based Measures
Elective Outpatient Percutaneous Coronary Intervention (PCI)
Knee Arthroplasty
Revascularization for Lower Extremity Chronic Critical Limb Ischemia
Routine Cataract Removal with Intraocular Lens (IOL) Implantation
Screening/Surveillance Colonoscopy
Acute Kidney Injury Requiring New Inpatient Dialysis
Elective Primary Hip Arthroplasty
Femoral or Inguinal Hernia Repair
Hemodialysis Access Creation
Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
Lumpectomy Partial Mastectomy, Simple Mastectomy
Non-Emergent Coronary Artery Bypass Graft (CABG)
Renal or Ureteral Stone Surgical Treatment
Melanoma Resection
Colon and Rectal Resection
Acute Inpatient Medical Condition Episode-based Measures
Intracranial Hemorrhage or Cerebral Infarction
Simple Pneumonia with Hospitalization
ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)
Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Lower Gastrointestinal Hemorrhage (applies to groups only)
Sepsis
Chronic medical condition episode-based measures
Diabetes
Asthma/Chronic Obstructive Pulmonary Disease (COPD)
Bottom line: the Cost category can be overwhelming and detrimental to your score if ignored. The cost category is dynamic and accounts for as much as the Quality category, but lacks the means for monitoring the result and score outcomes. Being educated on the measures, how they are triggered, knowing how you have scored in the past, as well as understanding attribution are all key to earning a good Cost score outcome.
Watch this space for more information throughout the year as we explore these measures in greater detail to help you understand the methodology for each cost measure.
Chirpy Bird can help you implement two key operational and administrative tasks to mitigate the negative impact of the Cost category on your MIPS score. Sign-up for monthly MIPS guidance now.
