We’ve seen a steady stream of questions coming in after our recent 2017 Final Rule MIPS webinars that I’d like to share with all of you. Missed the webinars? We’ve posted the recordings and slides in our Resource Center.

I hope this Q&A format will help provide a better grasp on some difficult-to-understand topics and questions about MIPS and the Quality Payment Program set to begin on January 1, 2017. Browse through them, and you might find an answer to one of your questions, or a question you didn’t even realize you had!

Still have a question after reading my post? I’m here to help. I invite you to submit your question in the comments section below. I’ll be standing by to answer them.

Let’s get started:

Incentives and Penalties.

Q.  Are incentives and/or penalties applied to all charges including labs and radiology? Or just office visits?

A.  Under PQRS and MIPS, payment adjustments apply to all Medicare Part B charges.  If the billed code is from the Medicare Part B Physician Fee Schedule, and there is an allowable charge in the schedule, it is included in the adjustment calculation.

Q.  If you received a negative adjustment under PQRS will this carry through to MIPS?

A.  Penalties (also known as payment adjustments) are applied two years after the performance year. Adjustments are specific to the program and to the performance and payment years and do not carry over from year-to-year or program-to-program.

Measures, Benchmarks, and General Participation.

Q.  I’m having trouble finding the measures for the different MIPS categories.  Can you help with a link or reference material that lists the measures for Quality, ACI and Clinical Practice categories?

A.  Medicare is doing a good job making their materials more readable and understandable.  The best material I have seen is collected at https://qpp.cms.gov/measures/performance

The quality measure specifications were released on November 14.

As we further interpret and find nuance in the rule and measures, we will publish various reviews, strategic guidance, and synopsis here on our website.

Q.  Do topped out measures apply in 2017?

A.  No measures will be treated as topped out in 2017.  They will be listed and active in the 2018 performance year.

Topped out measures are measures where a significant number of providers get perfect or near-perfect scores.  Many decile ranks will cluster together.  Medicare plans not to retire topped out measures, but to create a disincentive for their use.  Topped out measures can never give you a top performance score.  The “cluster of deciles” will be scored at the midpoint of the cluster.  For example, if 50% of providers report 100% performance on measure T, the score for anyone in the cluster will be 7.5, the midpoint between the 5th and 10th deciles.

Before you abandon all topped out measures, however, consider that others are not topped out because they are harder to achieve a high performance score.  If a measure was easy, it would be topped out too.

Q.  Do you know when CMS will have benchmarks available for the quality measures?  How will I be able to find these? 

A.  The benchmarks for the first MIPS performance year were released December 29, 2016. You can download the zip file from this page:  https://qpp.cms.gov/resources/education

Q.  Do I need to do have at least 20 eligible instances for the measure to count? I only do approximately 40 related procedures a year, so it would be very difficult to do 20 in 90 days.

A. In MIPS, you can submit a measure with a denominator of any size, but it will only be scored if the denominator is ≥ 20.

That threshold of 20 is applicable to the 90-day reporting period in 2017.  Medicare believes that 20 is the minimum sample size that is statistically significant.

You can take one of two approaches:

1. Submit a small sample with fewer than 20 cases for a 90-day period in 2017.  CMS will count the measure against the 6-measure requirement, but will not average your performance into your category score.
2. Submit for more than 90 days.  You are not restricted to a 90-day reporting period in 2017.  You can submit anything between 90 and 365 days and get full credit for your submission.  But you cannot vary the performance window measure by measure.  CMS insists that you use the same time frame for all of your quality measures.

Q.  Will specialty measure sets have the same format as Measures Groups for PQRS without the 20 patient requirement?

A. Not exactly. The specialty measure sets function mostly as suggestions for specialists.  You can choose from the measures or go outside the measure set.  There is one rare advantage of the specialty measure set.  If your specialty measure set has fewer than 6 measures in it, Medicare will consider your submission to be complete if it contains all of the measures of the specialty measure set.

Q.  Can we decide if we have an applicable outcome measure or is there a MAV type process?

A.  You can decide. There is not yet a Measure Applicability Validation (MAV) process for MIPS.  There may be one introduced for the 2018 performance year. If you conclude that there is not an outcomes measure, intermediate outcome measure, or high priority measure that is applicable to you, you are likely going to have to defend your conclusion in an informal review.

Q.  Our group is a multi-specialty practice with Eyecare and ENT.  If we report as a GPRO, can we pick one specialty measure group and have it apply to all the EPs in the group?

A.  Yes, you can do that. The measures are the same for the whole group, and do not have to apply to all providers in the group.  I would beware in one circumstance.  In the rare case that a specialty measure set has fewer than 6 measures in it, a single specialty group can get full credit for a submission that contains all of the measures in the specialty measure set, but fewer than 6 measures.  A group with more than one specialty will need to go outside the single specialty measure set to find and submit 6 measures.

Q.  If I report for a 90-day performance period, do I need 20 instances in 90 days or just 5?

I am a Vascular Surgeon so several of the quality measures are dependent upon the number of surgeries I do and although I wish I did 80 a year of aneurysms and carotids and fem-pops that is not realistic.

A. Medicare has discontinued Measures Groups as of the 2017 performance year.

This plan gets rid of both the 20-patient sample you have relied on to make your data abstraction doable.  And we also lose all of the measures that are Measures Group measures only.

Your reporting requirement is 50% of the eligible cases for the 6 measures you choose to report.  The 50% is relevant to your patients seen in one 90-day window that you choose in 2017.

I am continuing to lobby to bring Measures Groups back in 2018.  I have submitted comments to that effect and I will repeat my comments when the next proposed rule comes out.

Medicare says, in the final rule:

“Comment: Several commenters recommended that CMS reinstate measures group reporting as an option under MIPS.

“Response: We did not propose the measures group option under MIPS because, as commenters noted, very few clinicians utilized this option under PQRS. Under the MIPS, we substituted what we believe to be a more relevant selection of measures through specialty specific measure sets. Adopting this policy also enables a more complete picture of quality for specialty practices. We do not believe the specialty-specific measure set will pose an undue burden on small practices, and may make it easier for eligible clinicians, including those in small practices, to easily identify quality measures to report to MIPS. We will continue to assess this policy for enhancements in future rulemaking.”

Your comments to Medicare might make a difference.

Q.  For the low-volume threshold, one of the possible exemptions is providers that have “less than 100 unique patients”.  We have been unable to find clarification on Medicare’s website to exactly what this means. Would this apply only to patients that our providers have performed E/M services? Surgeries also?  Diagnostic services—both with and without face-to-face components?  Do you have any insight you can give regarding this?

A. I interpret this as follows:

Look at all billing for the year submitted to Medicare Part B that relate to an allowable charge on the physician fee schedule.

Count each distinct patient you find only once no matter how many times each was seen.  E&M visits and procedure visits are equally applicable.  Diagnostic services are relevant if, and only if, they are billed through Medicare Part B.  All Medicare Part B charges are relevant whether they are face-to-face or not.

If that number is less than 100, you may be qualified for the low volume exclusion.

I say “may be qualified” because Medicare is going to be doing this count for you.  And they are doing it in each of 2 years prior to your submission year.  If you are low volume in either of those years, you are low volume.  Otherwise you do not exclude.

You can measure this yourself to get an idea whether or not you will exclude.  We will do that measurement on all data sets that we handle.  But all data sets differ to some extent due to many factors I will not get into here and now.  Medicare’s measurement is the only one that counts.  Medicare intends to make the data available to you before January 1, 2017, whether you exclude by low volume or not.  I assume you will be able to find that designation in your Medicare QualityNet Portal.

Q.  In your 11/9/16 webinar, you indicate that physicians are required to report quality measures for all payers. However, I had emailed the QPP Help Desk and asked them who the targeted population is for 2017 MIPS. Their answer was “The 2017 MIPS reporting year is strictly applied to only Medicare Part B FFS patients.” 

Do you know why this discrepancy? If required to submit data on patients of all payers, I believe it would be a significant burden for most providers. I was relieved when I received the Help Desk answer, but am now again concerned seeing your webinar slide…

A.  In the version of the final rule published on the Federal Register on November 4, on page 77126 of the Register (page 119 of the downloaded PDF) there is a table labeled Table 5 that summarizes the final data completeness criteria for the 2019 payment year (the 2017 performance year).

The second row of the table is relevant to Qualified Registry, Qualified Clinical Data Registry, EHR Direct, and Data Submission Vendor submission mechanisms.

The last column documents the Data Completeness Criteria for the row:

“50 percent of MIPS eligible clinician’s or groups patients across all payers for the performance period.”

Your help desk helper would be correct if answering about Claims, Web Interface, or Survey Measures submission mechanisms.

Of course, we have seen cases when Medicare does not operationalize the rules as written.  But more often I see mistakes in how the help desk explains them.

My advice to you is, get all answers from the help desk in writing.  If you have it in writing, you follow their advice, and Medicare judges your submission poorly, you can use that documentation to support your informal review.  Otherwise, you are better off following the written rules and ignoring the help desk advice.

Medicare Risk Adjustment Factor.

Q.  Our QRUR states our attributed beneficiaries are in the 90th percentile for high risk.  However, we are not eligible for the high risk bonus due to the lack of strong performance with quality and cost measures.  It also states that a risk and specialty adjustment factor is applied to our cost measures.  How do we know the amount of the risk adjustment?  Is that calculation public, or convoluted as all other calculations? 

A.  Unfortunately, CMS does not provide the numerical basis of their adjustments.

The risk adjustment is based solely on the Hierarchical condition codes (HCC codes) from which CMS develops a risk score for each patient from which they have traditionally adjusted provider payments through Medicare Advantage Plans.  We are now seeing those HCC codes effecting Medicare Part B payments through this risk adjustment that is applied to both Quality and Resource Use performance calculations.  This will extend into the MIPS program.

Your score in the 90th percentile indicates you take care of extraordinarily high complexity high risk patients.  But having only your percentile ranking is not enough data to mathematically recreate the risk adjustment.

As for Specialty adjustment, Medicare provides nothing with which to recreate or predict those adjustments.

Our database now holds data on 32,000 providers representing all specialties, all States, all practice sizes.

We have the HCC codes submitted to Medicare for most of our client-providers.  As we move into MIPS and performance counts more than ever before, we will use your HCC codes to predict the risk adjustment and expect to be close, but not dead-on Medicare’s calculations.

We will also be able to make a good approximation of the Specialty adjustment to give our clients guidance.  But again, it will not precisely match Medicare’s calculations.

Is Mingle Health a Registry? What are your capabilities?

Q.  Is Mingle considered a “Qualified Registry” or a “Qualified Clinical Data Registry”?

A.  Mingle Health supports all measures and all submission mechanisms.  We are both a Qualified Registry and a Qualified Clinical Data Registry. We are also Certified Electronic Health Record Technology for the purpose of submitting EHR Direct or as a Data Submission Vendor.  We support ACO Reporting and GPRO web interface reporting as an electronic upload and can qualify your submission for the all-electronic workflow bonus points.  Talk with our team about how we can meet your quality reporting needs.

Did you find this helpful? You can find more of Dr. Mingle’s responses to commonly asked questions in his blog post, Q&A on MIPS with Dr. Dan Mingle – Part 2

Looking for more answers? Post your questions in the comments below. You can also find additional information on our MIPS FAQ page, in our free E-Book, or by contacting our team of friendly consultants to make sure you are prepared for the new Quality Payment Program starting in 2017!