Trying to understand the Merit-based Incentive Program (MIPS) may have you scratching your head — especially the Cost category. And that is understandable.

The Cost category is mysterious, if not downright confusing at times. In this category, a provider doesn’t need to enter information into the Quality Payment Program (QPP). Instead, this information is captured through Medicare Parts A and B claims. As the fourth performance category for MIPS, it makes up 15 percent of the total MIPS score for 2020.

The Centers for Medicare & Medicaid Services (CMS) calculate the Cost category from data submitted on Medicare claims during the Jan. 1-Dec. 31 MIPS performance year.

It is important to have an understanding of how things come together for a score, know how to determine measures that apply to your practice and ways you can impact your score. To fully understand the Cost category, you need to understand the three measures CMS uses to calculate the Cost score.

Each measure has specific eligible case minimums that must be accomplished for the measure to receive the score. Not meeting the case minimum for any cost measure means CMS is unable to calculate the Cost score and the category will be reweighted to Quality.

Measure 1: Medicare Spending per Beneficiary (MSPB)

The MSPB measure evaluates clinicians and groups based on the cost for inpatient stays compared to the national benchmark. The measure evaluates both Medicare Part A and Part B claims during three days before, during, and 30 days following an inpatient hospital stay. In order for Costs to be attributed to a clinician or group, there must be a minimum of 35 eligible cases of Medicare Part B charges during an episode for the MSPB score to be calculated. Pay close attention to transitional care as patient follow-ups will help bypass readmissions and adverse drug events.

Measure 2: Total per Capita Cost (TPCC)

The TPCC measure calculates the overall Medicare Parts A and B claims’ cost of care provided to a beneficiary receiving primary care services during the performed period based on a minimum of 20 eligible cases. While the measure typically affects primary care and internal medicine clinicians, it may be assigned to a specialist if the specialist provides more primary care services to a patient.

The TPCC has two steps when determining attribution to a patient’s cost:

Step 1: If a beneficiary received more primary care services from an individual Tax Identifier Number/National Provider Identifier (TIN-NPI) that is classified as either a primary care physician (PCP), nurse practitioner (NP), physician assistant (PA) or clinical nurse specialist (CNS) than from any other TIN-NPI during the performance period, then the beneficiary is attributed to that TIN-NPI.

Step 2: If a beneficiary did not receive a primary care service from a TIN-NPI classified as either a PCP, NP, PA, or CNS during the performance period, then the beneficiary may be assigned to a TIN-NPI to determine the outcome. Performing Annual Wellness Visits (AWV) for your Medicare beneficiaries will positively impact your TPCC score. The AWV gives a clinician the opportunity to discuss overall health potentially unveiling a developing chronic condition as well as the opportunity for preventive measures. Catching a condition early and preventing an episode are very important ways to reduce costs.

Measure 3: Episode-based Group

An episode group assesses the cost of both Medicare Parts A and B claims specifically related to an acute inpatient stay or procedure. This is different than MSPB which is related to all costs during an inpatient stay. Episode groups are procedural episodes, such as a colonoscopy, or emergency care such as simple pneumonia with an inpatient stay. The case minimum for a procedural episode is ten and for an acute episode, the minimum is twenty. These episodes are attributed to triggering codes such as colorectal cancer screening colonoscopy G0105. The best way to positively impact the scoring of these measures is by using evidence-based protocols. The challenge is to resist becoming complacent due to repetition.

The following measure overview chart (Fig. 1) allows you to quickly assess potentially attributed cost episodes and tips on how to impact scoring for those measures.

Fig. 1

While we may not have explained everything involved with the Cost category, we hope that this overview takes some of the mystery and confusion many providers have felt. If you have questions or need assistance, please contact us.