December 11, 2018

Key Takeaways for 2019 Quality Payment Program

On November 1, 2018, CMS issued the Calendar Year 2019 Quality Payment Program (QPP) final rule for the third transition year for physicians to begin participation in either the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

The third transition year increases the potential MIPS payment adjustments to +/- 7% for payment year 2021. These policies become effective on January 1, 2019.

Nine Key Takeaways

ACR volunteers and staff created a detailed summary of the QPP Final Rule, but here are nine key changes impacting radiologists in the coming year.

1. Low-Volume Threshold

CMS added a third criterion for exempting physicians from MIPS in 2019:

  • Have ≤ $90K in Part B allowed charges for covered professional services; OR
  • Provide care to ≤ 200 Part B beneficiaries; OR
  • New: Provide ≤ 200 covered professional services under the Medicare Physician Fee Schedule   

Physicians or groups that exceed one, but not all, of the low-volume criteria can now opt-in to MIPS participation in order to receive a payment adjustment.

2. Category Weights

  • Quality: 45% (down from 50% in 2018)
  • Cost: 15% (up from 10% in 2018)
  • Promoting Interoperability (PI): 25% (unchanged)
  • Improvement Activities (IA): 15% (unchanged)

3. Quality Category

CMS will maintain the 60% data completeness threshold for QCDRs, qualified registries, EHRs and claims-based data submissions (with the expectation that this threshold will increase over time). Other key changes in the Quality category include:

  • Five measures relevant to radiologists were finalized for removal: #359 and #363 for diagnostic radiology; #99, #100 and #156 for radiation oncology.
  • New category of topped out measures: Measures with performance in the 98th-100th percentile will be considered “extremely topped out” and might be removed in the next performance year (rather than entering the three-year removal methodology).
  • Topped out Qualified Clinical Data Registry (QCDR) measures might also be removed in the next performance year (rather than entering the three-year removal methodology).

4. Promoting Interoperability Category

No major changes occurred in this category, but there is no longer a 10% PI category bonus for completing IAs using Certified Electronic Health Record Technology.

5. Cost Category

CMS added eight episode-based measures (in additional to total per capita cost and Medicare Spending Per Beneficiary measures) when determining performance in the Cost category:

  • 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
  • Intracranial Hemorrhage or Cerebral Infarction
  • Simple Pneumonia with Hospitalization
  • ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)

6. Improvement Activities Category

No major changes occurred in the IA category, but CMS added six new activities, modified five and removed one. Participation in the Radiology Support, Communications and Alignment Network (R-SCAN™) continues to count for seven medium-weighted IAs.

7. Non-Patient-Facing Clinicians

Non-patient-facing clinicians remain exempt from the PI performance category. For those clinicians, the 25% weight of the PI category will be applied to the Quality category.

The IA category requirements remain unchanged. Non-patient-facing clinicians can submit one high-weighted IA or two medium-weighted IAs for full credit in the category.

8. Considerations for Small Practices

CMS defines small practices as 15 or fewer clinicians. The following are considerations that CMS has established for small practices to help them meet MIPS requirements:

  • New: A bonus of six points will be added to the Quality performance category score for small practices; in previous years this was a bonus of five points to the overall MIPS score.
  • Small practices will receive three points for reporting measures that do not meet 60% data completeness requirement (as compared to clinicians in larger practices that receive one point for incomplete measures).
  • While most MIPS eligible clinicians will no longer have the option of reporting measures via claims submission, small practices will continue to be allowed this option.

9. Facility-Based Measurement

In the 2019 MIPS performance year, physicians can use a facility-based scoring option for the Quality and Cost categories. Key factors to consider for this type of MIPS scoring include:

  • To qualify for facility-based scoring, physicians must perform 75% of their services in inpatient, on-campus outpatient hospital or emergency room settings.
  • At least one service must be billed with the place of service code used for inpatient (21), on-campus outpatient hospital (22) or emergency room (23).
  • Facility-based physicians will be scored according to the Hospital Value-Based Purchasing (VBP) program measure set.
  • No opt-in is required. If facility-based physicians choose to participate in MIPS via other means, CMS will evaluate whether their MIPS or Hospital VBP score is higher, and they will be awarded the higher of the two.

Learn more by reading the ACR detailed summary of the QPP Final Rule.