Practice Alternatives

MIPS Category Weights

In 2021, the weight of the cost category will be increased to 20% (from 15% in 2020), in turn reducing the quality category weight to 40% (from 45% in 2020). The category weights for improvement activities (15%) and promoting interoperability (25%) remain the same. Starting in performance year 2022, MACRA requires CMS to weight the cost category at 30%.

The 2021 final rule continues to offer category reweighting for group practices and clinicians who are unable to submit data for one or more performance categories. In most cases, the weight of these categories will be redistributed to the quality category.

MIPS Final Score and Payment Adjustments

The 2021 MIPS performance threshold is 60 points. Although CMS proposed a 50-point threshold in the 2021 PFS, the agency previously finalized a 60-point threshold for the 2021 performance year and decided to maintain that policy rather than finalize the proposed threshold. The exceptional performance threshold is 85 points.

Thus, under the final rule, clinicians and group practices participating in MIPS must earn at least 60 points in 2021 to avoid a Medicare payment penalty of up to 9% in 2023. In addition, $500 million is available for clinicians and group practices whose final score meets or exceeds the exceptional performance threshold of 85 points. The maximum exceptional performance bonus is 10%, which is in addition to the maximum possible positive payment adjustment of 9%.

Complex Patient Bonus (up to 10%)

For 2020 only, the number of points available for the complex patient bonus is doubled from five to 10 points to account for the additional complexity of treating patients during the COVID-19 pandemic. In 2021, the complex patient bonus will be five points. This bonus is added to a clinician or group’s overall MIPS score.

Quality Category (40%)

CMS proposed to use current (2021) performance year benchmarks rather than historical benchmarks for the 2021 performance year due to concerns that the COVID-19 pandemic could skew benchmarking results. CMS did not finalize this proposal and decided to score 2021 performance based on historic (2019) benchmarks, as has been the policy for many years. This means group practices will be able to download benchmark data in advance and evaluate how performance will be scored against benchmark data.

CMS revised the policy for scoring measures that are impacted by significant changes during the performance year and expanded the list of reasons that a quality measure could be impacted. For each measure submitted by a clinician or group that is impacted by significant changes, CMS will base performance on data for nine consecutive months of the performance period. If such data is not available or may result in patient harm or misleading results, the measure is suppressed (e.g., clinicians are held harmless from a scoring penalty). Significant changes include, but are not limited to, changes to codes (such as ICD-10, CPT, or HCPCS codes), clinical guidelines, or measure specifications.

There are a total of 209 quality measures for the 2021 performance period. CMS made substantive changes to 113 existing MIPS quality measures and removed 11 measures. Additionally, CMS removed the All-Cause Hospital Readmission measure, which was calculated via administrative claims for groups of 16 or more clinicians that meet the case minimum of 200. In place of this measure, CMS added two new administrative claims quality measures:

• Hospital-Wide, 30-Day, All-Cause Unplanned Readmission Rate. Only applies to groups with 16 or more clinicians and that meet the case minimum of 200.

• Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). Only applies to groups that meet the case minimum of 25.

Lastly, CMS will retire the CMS Web Interface as a quality reporting option for ACOs, APM entities, groups, and virtual groups starting in 2022

Cost Category (20%) 

Cost measure specifications for episode-based measures and the total per capita cost (TPCC) measure will include applicable telehealth services. There are no significant updates to the current cost measure set, but group practices should review measure specifications to evaluate any changes.

Improvement Activities Category (15%)

There are no significant updates to this category in 2021. CMS will continue to allow reporting of the COVID-19 clinical data reporting improvement activity in 2021.

Promoting Interoperability Category (25%) 

The measure for query of prescription drug monitoring programs (PDMPs) will remain optional in 2021 and will be worth 10 bonus points (up from five). The PDMP measure is a “yes/no” measure that does not require reporting numerator/denominator counts.

CMS added an optional Health Information Exchange (HIE) bi-directional exchange measure as an alternative reporting option to the two existing measures for the HIE objective.