• MIPS 2019—Cost: The Total Per Capita Cost Measure

    This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page


    The Total Per Capita Cost measure takes into account all Medicare Part A and Part B costs incurred during 2019 for Medicare patients who are attributed to you. Here, in brief, is how it works.

    Which Medicare patients are included? A patient’s costs will only be factored into this measure if he or she receives primary care services during the performance period. Evaluation and management (E&M) office visits are viewed by CMS as primary care services.

    Which patients are attributed to you? CMS uses a two-step process to attribute patients—and their costs—to clinicians.

    • First step: CMS attributes patients to the primary care physician, nurse practitioner, physician assistant, or clinical nurse specialist who provides the most primary care services to that patient.
    • Second step: If the patient didn't see a primary care clinician (see "First step") during the year, the patient will be attributed to the non–primary care clinician who provided the most E&M visits.

    Because CMS is counting E&M services as primary care services, the E&M codes (CPT code 99201-99215) will be factored into the attribution process; the Eye visit codes (CPT codes 92002-92014) won’t. Regardless of whether you use E&M codes or Eye visit codes, you should bill the level of exam that your documentation supports.

    CMS tries to level the playing field. In an effort to compare providers fairly, CMS takes into account a number of factors, including:

    • payment factors that are unrelated to the care provided (e.g., geographic variations in Medicare payment policy);
    • patients who die or become newly enrolledduring 2019, and thus weren't Medicare beneficiaries for the full year (these have their costs annualized; for example, if they were only in Medicare for six months their costs would be doubled);
    • extreme outliers (these are determined through statistical methods);
    • certain risk factors that can affect medical costs; and
    • a physician’s specialty.

    There is a 20-patient case minimum. In order to get a score for this measure, at least 20 patients must be attributed to you.

    You score 1-10 points. Your score will depend on how your performance compares with other MIPS participants during the current performance year.

    A problematic measure. The Academy, along with other physician associations, has pointed out a number of flaws with this measure. The risk adjustment methodology is problematic, and attribution strategies are unreliable.

    Previous: Cost: The Routine Cataract Surgery with IOL Implantation Measure

    Next: Cost: The Medicare Spending Per Beneficiary Measure

    DISCLAIMER AND LIMITATION OF LIABILITY: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    COPYRIGHT© 2019, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.

    All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).