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  • MIPS 2023—Cost: Episode-Based Measures

    This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.

    For each episode-based cost measure, CMS will use Medicare claims data to 1) attribute relevant procedures to you and 2) track costs that are clinically associated with those procedures.

    The following two episode-based measures might apply to ophthalmologists:

    • Routine Cataract Removal With IOL Implantation
    • Melanoma Resection

    Which procedures are attributed to you? An episode of routine cataract surgery or melanoma resection will be attributed to the MIPS eligible clinician who performed the procedure that “triggers” the episode. That procedure is known as the “trigger service,” and the date it took place is the “trigger day.” For the cataract measure, if you bill CPT code 66984—which is the code for routine cataract surgery—an episode of cataract surgery will be attributed to you unless an exclusion applies. (Note: Billing CPT code 66982 for complex cataract surgery would not trigger an episode.)

    For the melanoma measure, CMS looks for CPT codes that indicate melanoma resection by removal of malignant growth; by adjacent tissue transfer or rearrangement procedures; or by repair of wounds using tissue transfer—but such CPT codes would only trigger an episode if accompanied by ICD-10 code C43 (malignant melanoma of skin) or D03 (melanoma in situ).

    Exclusions. For the cataract surgery measure, exclusions include significant ocular conditions, such as a retinal detachment, that might impact the outcome of the surgery. For the melanoma measure, exclusions include any patient who undergoes Mohs surgery at any time during a procedure’s five-month review period (see “What costs are included,” below). CMS reviews the patient’s Medicare claims history to see if there were any ICD-10 diagnosis codes that would flag such exclusions.

    A 10-episode case minimum. The cataract measure will only contribute to your cost score if at least 10 episodes of routine cataract surgery are attributed to you in 2023. The melanoma measure also has a 10-episode case minimum.

    What costs are included? These cost measures take into account only the cost of services that are clinically related to the cataract surgery or melanoma resection. CMS identifies those costs by reviewing the patient’s Medicare claims over a five-month period. For the cataract and melanoma measures, this review period—also known as the episode window—starts 60 days before the day of surgery (the trigger day) and ends 90 days after surgery (mirroring the familiar 90-day postoperative period).

    CMS tries to level the playing field. Your costs for the measure will undergo payment standardization and risk adjustment. This is intended to account for cost variations that are beyond your control, such as patient characteristics that may lead to increased spending and geographic variations in wage levels.

    Furthermore, CMS recognizes that costs for cataract surgery might vary depending on whether surgery was done in an ambulatory surgery center (ASC) or a hospital outpatient department (HOPD), and that costs also can vary depending on whether the cataract surgery is unilateral or bilateral (which it defines as the second surgery being done within 30 days of the first). Consequently, CMS divides episodes of routine cataract surgery into four subgroups and will only compare an episode’s costs against the cost of episodes within the same subgroup. The subgroups for routine cataract surgery are unilateral surgery in an ASC; bilateral surgery in an ASC; unilateral surgery in a HOPD; and bilateral surgery in a HOPD. 

    For the melanoma measure, CMS recognizes two subgroups: head/neck melanoma and trunk/extremity melanoma. (Note: The 10-episode case minimum requirement applies to the measure as a whole, not to the individual subgroups.)

    You score 1-10 points. You can get a score from each of a measure’s subgroups, and a weighted average will be used to calculate your measure score. Each subgroup score will be based on how your performance compares with that of other MIPS participants in that subgroup during the current performance year.

    Learn more about these measures. Visit the CMS Resource Library to download detailed measure specifications.

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