• MIPS 2018—Cost: The Total Per Capita Cost Measure

    Written By: Chris McDonagh, Cherie McNett, and Jessica Peterson, MD, MPH

    This content was excerpted from EyeNet’s MIPS 2018; 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 2018 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 score 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 2-step process to attribute patients—and their costs—to clinicians.

    First, CMS attributes the patients to the primary care physician, nurse practitioner, physician assistant, or clinical nurse specialist who provides the most primary care services to that patient.

    If the patient didn’t receive any primary care services from those types of clinicians, he or she will be attributed to the non–primary care clinician who provided the most office visits.

    Because CMS will be counting E&M services as primary care services, the E&M codes (CPT codes 99201-99215) will be factored into the attribution process; the ophthalmic exam codes (CPT 92002-92014) won’t. Regardless of whether you use E&M or ophthalmic exam 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. These include:

    • payment factors that are unrelated to the care provided (e.g., geographic variations in Medicare payment policy);
    • patients who weren’t Medicare beneficiaries for the full year (these have their costs annualized; for example, if they were only in Medicare for 6 months their costs would be doubled);
    • extreme outliers (these are determined through statistical methods);
    • 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, with ophthalmologists held responsible for hospitalizations that may not be related to eye care. The measure excludes outpatient prescription drugs, which skews scoring against physicians whose treatment options include procedural interventions rather than putting patients on maintenance drugs.

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    Previous: Cost: Its Role in MIPS.

    Next: Cost: The Medicare Spending Per Beneficiary Measure.

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