MIPS 2020—Small Practices Get a Break

You may be exempt from MIPS if you provided limited Medicare Part B services—in terms of allowed charges, patients seen, or actual covered services provided—over either of two 12-month segments of the MIPS determination period (see “Exclusion 2—eligible clinicians who are below the low-volume threshold”).

CMS developed the virtual group option for practices with 10 or fewer eligible clinicians. There was a Dec. 31, 2019, deadline for forming a virtual group for the 2020 performance year.

Suppose you report on a quality measure, but you don’t meet the 70%–data completeness criteria. If you are in a large practice, you would score 0 achievement points for that measure, but if you are in a small practice, and you report on at least one patient, you would score 3 achievement. points.

Clinicians in small practices have the option of reporting quality measures via claims, and they can do so whether participating in MIPS at the individual or at the group level.

One of the downsides of claims-based reporting is that it must be done in real time, which means you probably had to start early in the year if you want to satisfy the 70%–data completeness criteria.

Another problem is that many of the benchmarks for claims-based reporting are subject to scoring limitations, which can make it hard to get a high achievement points total (see the “Achievement Points” column in “Table: Reporting Quality Measures via Medicare Part B Claims”).

An upside is that, unlike manual reporting via the IRIS Registry, you don’t have to track the data-completeness totals, making claims-based reporting a reasonable option if you are just seeking to score 3 points for a quality measure with minimal reporting to help you avoid the penalty. 

When CMS calculates your quality score, it will add 6 points to your numerator if you are in a small practice provided that you submit data on at least one quality measure.

If you are in a small practice, you can apply for a small practice significant hardship exception; if approved, PI’s weight in your MIPS final score would be reweighted to 0% and quality reweighted upward.

Clinicians with a special status, such as being in a small practice, receive double points for each improvement activity that they perform. This means that they don’t have to jump through as many hoops to get a 100% score for the improvement activities performance category. For example, a clinician with a special status can score 100% by performing one high-weighted activity while a practice without such a status would have to perform two of them (see “How You Will Be Scored”).

Dr. Argus reports as an individual. He doesn’t perform cataract surgery, so he doesn’t expect to be scored on cost. CMS accepts his applications for a small practice hardship exception from PI, so he is excused from that performance category. Consequently, his MIPS final score will be based on his improvement activities score and his quality score, which would be weighted at 15% and 85%, respectively. (Note: CMS has said that it would start processing PI exception applications in early summer, but in the past it hasn’t done so until August.)

Dr. Argus performs and attests to one high-weighted improvement activity, and he scores 100% for that performance category. This contributes 15 points to his MIPS final score.

Because it takes 45 points to avoid the MIPS penalty, Dr. Argus needs his quality score to contribute at least 30 points to his MIPS final score.

Quality is weighted at 85% of his MIPS final score, so he will need a quality score of at least 35.3% (35.3% of 85 points = 30 points).

What does he need to do to get a quality score of 35.3%? Small practices can earn 3 achievement points for a quality measure with minimal reporting—which could be as little as reporting on one qualifying patient just one time. If he does that for six quality measures (including at least one outcome measure) his quality score would be calculated as follows:

• Numerator: achievement points total (18 points) + measure bonus points (0 points) + small practice bonus (6 points) = 24 points
• Denominator: available achievement points (60 points) = 60 points
• Quality score = numerator (24) ÷ denominator (60) = 0.4, or 40%.

His MIPS final score would be 49 points, with his quality score of 40% contributing 34 points (40% of 85 points) and his improvement activities score of 100% contributing 15 points. This would be enough to avoid the penalty, but with not much margin for error.

To tweak the previous example, suppose Dr. Argus is a cataract surgeon.

He is now scored on cost, after meeting the case minimum for the cataract surgery measure. Cost is weighted at 15% when CMS calculates his MIPS final score.

As in the previous example, CMS accepts his applications for a small practice hardship exception from PI, so he is excused from that performance category.

He is scored on quality and improvement activities, which are weighted at 70% and 15% of his MIPS final score, respectively.

If he performs one high-weighted improvement activity, he scores 100% for that performance category, which contributes 15 points to his MIPS final score.

He still needs to score 30 points to reach the 45-point threshold for avoiding the penalty.

Because he doesn’t know what his cost score will be, he should try to score at least 30 points for quality. He can do that as follows:

• report six quality measures, with at least one being an outcome measure;
• meet the two data submission thresholds for two of those measures and earn a total of 8 points for them; and
• for the remaining four measures, report on at least one qualifying patient per measure, earning 3 achievement points for each measure for a total of 12 points.

His quality score would be calculated as follows:

• Numerator: achievement points total (20 points) + measure bonus points (may earn bonus points for the two fully reported measures) + small practice bonus (6 points) = at least 26 points
• Denominator: available achievement points (60 points) = 60 points
• Quality score = numerator (26) ÷ denominator (60) = 0.43, or 43%

His MIPS final score would be 45 points, with his quality score of 43% contributing 30 points (43% of 70 points) and his improvement activities score of 100% contributing 15 points. This would be barely enough to avoid the penalty.

For further information on what you might do to avoid the penalty, see "Step 4" of the Small Practice Roadmap.