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Merit-based Incentive Payment System: 2019 Changes

Hess, Cathy Thomas BSN, RN, CWCN

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Advances in Skin & Wound Care: February 2019 - Volume 32 - Issue 2 - p 94-96
doi: 10.1097/01.ASW.0000552866.40487.07
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On November 1, 2018, The Centers for Medicare & Medicaid Services (CMS) released the final changes to the 2019 Quality Payment Program (QPP) Final Rule1 under the Medicare Access and CHIP Reauthorization Act of 2015 law. In this column, we will review the 2019 Merit-based Incentive Payment System (MIPS) changes. This information is not exhaustive, and it remains your responsibility to read and understand how these changes affect your practice needs. The Table provides the CMS references used in compiling these changes so you can build your resource library.


Terminology Changes

The CMS has created new MIPS terminology that more accurately reflects how clinicians and vendors interact with the QPP, namely MIPS. The new MIPS terms include Collection Type, Submitter Type, and Submission Type.

  • Collection type: a set of quality measures with comparable specifications and data completeness criteria including, as applicable, electronic clinical quality measures (eCQMs), MIPS clinical quality measures (CQMs), Qualified Clinical Data Registry (QCDR) measures, Medicare Part B claims measures, CMS Web Interface measures, the Consumer Assessment of Healthcare Providers and Systems for MIPS survey measure, and administrative claims measures.
  • Submitter type: the MIPS eligible clinician (EC), group, or third-party intermediary acting on behalf of a MIPS EC or group, as applicable, that submits data on measures and activities.
  • Submission type: the mechanism by which the submitter type submits data to CMS, including, as applicable, direct, log in and upload, log in and attest, Medicare Part B claims, and the CMS Web Interface. There is no submission type for cost data because the data are only submitted for payment purposes.

Participation Status2

Each year, the CMS provides a list of providers that are required to participate in the QPP MIPS. This year, known as year 3, CMS expanded the definition of MIPS ECs to include new clinician types including physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals. Providers from the previous year remain included: physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups or virtual groups that include one or more of the clinician types above.

Clinicians or groups have the ability to “opt in” to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria. Those clinicians who opt in to the MIPS program would be subject to neutral, negative, or positive payment adjustments based on their MIPS performance and final score.

MIPS Determination Period

The CMS stated that they have created a streamlined and consistent “MIPS Determination Period” that will be used to evaluate clinicians and groups for

  • the low-volume threshold,
  • non–patient-facing status,
  • small practice status, and
  • hospital-based and ambulatory surgical center–based statuses.3

This period includes two 12-month segments:

  • first segment: October 1, 2017 to September 30, 2018 (including a 30-day claims run-out);
  • second segment: October 1, 2018, to September 30, 2019 (does not include a 30-day claims run-out).

Note that these 12-month segments now align with the fiscal year and begin October 1st.

Performance Thresholds and Payment Adjustments

The CMS is doubling the MIPS performance threshold in 2019. All MIPS ECs and groups have to earn at least 30 MIPS points to ensure a neutral payment adjustment.

Further, the CMS is increasing the exceptional performance bonus in 2019 for the top MIPS performers. Clinicians and groups seeking an exceptional performance bonus would need to earn at least 75 MIPS points.

As required by statute, the maximum negative payment adjustment is -7%. Positive payment adjustments can be up to 7% (but they are multiplied by a scaling factor to achieve budget neutrality).

Eligible Clinician or Group Reporting Status

The CMS states they are committed to continue helping small practices in year 3 by

  • increasing the small practice bonus to 6 points, but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus;
  • continuing to award small practices 3 points for submitted quality measures that do not meet the data completeness requirements;
  • allowing small practices to continue submitting quality data for covered professional services through the Medicare Part B claims submission type for the Quality performance category;
  • providing an application-based reweighting option for the Promoting Interoperability performance category for clinicians in small practices;
  • continuing to provide small practices with the option to participate in MIPS as a virtual group; and
  • offering no-cost, customized support to small and rural practices through the Small, Underserved, and Rural Support technical assistance initiative.

Low-Volume Threshold

The low-volume threshold now includes a third criterion for determining MIPS eligibility. To be excluded from MIPS, clinicians or groups need to meet one or more of the following three criteria:

  1. Have $90,000 or less in Part B allowed charges for covered professional services;
  2. provide care to 200 or fewer Part B enrolled beneficiaries; OR
  3. provide 200 or fewer covered professional services under the Physician Fee Schedule.

If a MIPS EC is scored on fewer than two performance categories, the final scoring policy is the same as year 2.

Promoting Interoperability

The Minimum Performance Period for this category is continuous 90 days, and the weight of the Performance Score remains 25%.

The CMS has overhauled the MIPS Promoting Interoperability (PI) performance category to support greater electronic health record interoperability and patient access while aligning with the Medicare PI Program requirements for hospitals. This has involved moving clinicians to a single, smaller set of objectives and measures with scoring based on measure performance for the PI performance category.

Further, ECs must use the 2015 Edition Certified Electronic Health Record Technology in year 3.

The CMS has also eliminated base, performance, and bonus scores by

  • finalizing a new scoring methodology;
  • implementing performance-based scoring at the individual measure level. Each measure will be scored based on the MIPS EC’s performance for that measure based on the submission of a numerator or denominator, or a “yes or no” submission, where applicable;
  • finalizing the Security Risk Analysis measure as a required measure without points; and
  • adding the scores for each of the individual measures to calculate the score of up to 100 possible points. If exclusions are claimed, the points for measures will be reallocated to other measures.

Other changes include using four objectives: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed.

The CMS has also added two new measures for the e-Prescribing objective: Query of Prescription Drug Monitoring Program and Verify Opioid Treatment Agreement as optional with bonus points available.

Quality Performance

The Minimum Performance Period is 12 months, and the weight of the Performance Score is now 45%.

In year 3, individual ECs can submit measures via multiple collection types (MIPS CQM, eCQM, QCDR, and for small practices, Medicare Part B claims measures). If the same measure is submitted via multiple collection types, the one with the greatest number of measure achievement points will be selected for scoring. The QCDR, MIPS CQM, eCQM, and claims collection types require at least six measures to be selected, with at least one an outcome measure. If an outcome measure is not available, another “high-priority” measure (appropriate use, patient safety, efficiency, patient experience, care coordination, or opioid-related measure) can be reported.

The CMS has maintained the same reweighting criteria for the Quality performance category. Data completeness requirements also remain the same as year 2 at 60% of eligible cases over the entire year, regardless of payer. Measures that do not meet data completeness requirements will get 1 point instead of 3 points. Small practices (15 practitioners or fewer associated with the Taxpayer Identification Number) will continue to get 3 points. However, for groups that submit five or fewer quality measures and do not meet the Consumer Assessment of Healthcare Providers and Systems for MIPS sampling requirements, the quality denominator will be reduced by 10, and the measure will receive zero points.

High-priority measures will include quality measures that relate to opioids.

High-Priority Bonus Points (after first required measure) are allocated as follows:

  • 2 points for outcome, patient experience;
  • 1 point for other high-priority measures that need to meet data completeness and case minimum and have performance greater than 0;
  • capped bonus points at 10% of the denominator of total Quality performance category; and
  • no high-priority measure bonus points for CMS Web Interface reporters.

Improvement Activity

The Minimum Performance Period is continuous 90 days, and the weight of the Performance Score remains 15%.

There is no change in the number of activities that MIPS ECs have to report to reach their total points.


The Minimum Performance Period is 12 months, and the weight of the Performance Score is now 15%.

There is no data submission requirement for the cost performance category. Cost measures are evaluated automatically through administrative claims data, which do not require clinicians to separately report these data.


1. Federal Register. A Rule by the Centers for Medicare & Medicaid Services on 11/23/2018. 2018. Last accessed December 20, 2018.
2. Quality Payment Program. About MIPS Participation. Last accessed December 20, 2018.
    3. Centers for Medicare & Medicaid Services. ASC Quality Reporting. 2018. Last accessed December 20, 2018.
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