This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.
Cost is one of four performance categories that can contribute to your 2023 MIPS final score.
Default weight in MIPS final score: 30%.
This year, the MIPS cost measures include:
- the Total Per Capita Cost (TPCC) measure,
- the Medicare Spending Per Beneficiary measure, and
- 23 episode measures (up from 18 last year), including one for routine cataract surgery and another for melanoma resection.
Only one or two cost measures are likely to apply to ophthalmologists. As an ophthalmologist, you may be scored on the cataract surgery measure. Also, some oculofacial specialists may be scored on the Melanoma Resection measure. However, the other 21 episode-based cost measures don’t apply to ophthalmology; the TPCC measure explicitly excludes ophthalmologists and optometrists; and the Medicare Spending Per Beneficiary measure focuses on inpatient hospitalization costs.
Performance period is the full calendar year. When CMS evaluates you on cost, they will include the cost of items and services that were provided from Jan. 1, 2023 to Dec. 31, 2023.
No reporting requirements. Cost is the only one of the four performance categories where you don’t report data or make attestations. CMS evaluates clinicians’ cost score based on Medicare claims data for patients that it attributes to them.
Won’t apply to all ophthalmologists: You are only likely to be scored on cost if you perform cataract surgery and/or perform melanoma resection and/or are in a multispecialty practice that reports as a group.
What if you don’t get a cost score? If you don’t meet the case minimum for the cataract surgery measure, and assuming you aren’t scored on any of the other cost measures, cost’s contribution to your final score will be reweighted to 0%, and one or more other performance categories will be reweighted upward (see “Reweighting the Performance Categories”).
You May Get a Cost Improvement Score
Who gets a cost improvement score? CMS only will calculate a cost improvement score for you if you use the same identifier in 2023 as you did in 2022 (see “Use of TINs and NPIs as Identifiers”).
How CMS calculates your cost improvement score? If you are scored on one or more cost measures in both 2022 and 2023, the number of cost measures with a statistically significant decline in performance is subtracted from the number with a significant improvement. The result is divided by the number of cost measures that were scored for both years. The resulting fraction is multiplied by the “maximum cost improvement score,” which is 1%. If, for example, you are scored only on the cataract measure in 2022 and 2023, and there was no significant improvement in 2023, then your cost improvement score would be 1%.
You can't get a negative score? The minimum cost improvement score is 0%.
Update: In legislation that was published in the Federal Register on Nov. 16, 2023, CMS stated that this scoring methodology outlined above would be “resource intensive, complex to implement, and error prone,” and replaced it with a simplified methodology. Under the new methodology, your cost improvement score = ([your increase in cost performance category score from 2022 to 2023] ÷ your 2022 cost performance category score) × “maximum cost improvement score.” The maximum cost improvement score is currently 1.
How CMS Calculates Your Cost Score
This can be described as a three-step process.
- Your achievement point total is your numerator. For each cost measure you are scored on, you will receive 1 to 10 achievement points based on how your performance compares to the measure’s benchmark.
- The number of points available to you is your denominator. If you are only scored on the cataract surgery measure, then your denominator would be 10.
- CMS does the math. After dividing the numerator by the denominator, CMS turns the result into a percentage, and adds any cost improvement score. The result is your cost performance category percent score, which contributes up to 30 points to your MIPS final score.
Example. After the performance year is over, CMS determines that a clinician only met the case minimum for the cataract surgery cost measure. Suppose the clinician scores 6.0 achievement points for that measure. Her numerator is 6.0 and, because she was only scored on one cost measure, her denominator is 10. So her cost score is 6.0 ÷ 10 = 0.60, which is reported as a percentage: 60%. (If there was a cost improvement score, it would be added to the 60%.) If cost is weighted at 30% of your MIPS final score (0-100 points), a cost score of 60% would contribute 18 points (60% of 30 points) to that score.
Previous: Table: Improvement Activities at a Glance
Next: Cost: Total Per Capita Cost Measure
DISCLAIMER AND LIMITATION OF LIABILITY: All information provided by the American Academy of Ophthalmology, its employees, agents, or representatives participating in the Academy’s efforts to explain regulatory and reimbursement issues is as current and reliable as reasonably possible. The Academy does not provide legal or accounting services or advice. You should seek legal and/or accounting advice if appropriate to your situation.
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 either 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© 2023, 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 Ophthalmology ®, American Academy of Ophthalmic Executives®, IRIS®, the Focus logo, and Protecting Sight. Empowering Lives ®, among other marks, are trademarks of the American Academy of Ophthalmology®.