MIPS 2020

January 27, 2020
by Dom Simonetta
Adjustments in the MIPS program are steep. After the 2019 reporting year, clinics won’t see any changes until 2021, when penalties/incentives take effect. These penalties/rewards will appear on the clinic’s future reimbursements from Medicare, depending upon their score.
 
For the 2020 reporting year, the stakes for these penalties and rewards rise to a maximum 9%, with the program expected to continue rising for a few more years. The two-year delay will remain constant as well.
 

One thing to keep in mind though, is that the program is budget neutral, meaning all the payment incentives for the people at the top of the program will come from the penalties taken from the people at the bottom. The only exception to this is the Exceptional Performance Bonus, which is paid no matter how much money is taken from the bottom end. Because of this, there is no way to guarantee a clinic will receive a particular percentage or dollar amount, as we have no way of knowing how other participants in the program will perform.

Penalties/Rewards

Adjustments in the MIPS program are steep. After the 2019 reporting year, clinics won’t see any changes until 2021, when penalties/incentives take effect. These penalties/rewards will appear on the clinic’s future reimbursements from Medicare, depending upon their score.
 
For the 2020 reporting year, the stakes for these penalties and rewards rise to a maximum 9%, with the program expected to continue rising for a few more years. The two-year delay will remain constant as well.
 

One thing to keep in mind though, is that the program is budget neutral, meaning all the payment incentives for the people at the top of the program will come from the penalties taken from the people at the bottom. The only exception to this is the Exceptional Performance Bonus, which is paid no matter how much money is taken from the bottom end. Because of this, there is no way to guarantee a clinic will receive a particular percentage or dollar amount, as we have no way of knowing how other participants in the program will perform.

 

Eligibility/Requirement

So now you know a little more about what the MIPS program is, which leaves the big question: how does a clinic know whether they have to participate? The short answer here is that it is very, very difficult to know for sure. So, you will have to make some tough decisions based on the data we have currently available.  There are a few different factors that we have to take into account here:
 
  1. There are 3 determination thresholds. If a provider meets 1 or 2 of the thresholds, they are eligible to participate and can choose whether or not the risk/reward is worth it to them. If the provider meets all 3, or will meet all 3 by 9/30/2019, they are required to participate.
  2. Determinations are made on an individual provider basis, even if your clinic bills as a group.
    The determinations are as follows:
    • Greater than 200 units billed to Medicare
    • Greater than 200 distinct Medicare patients
    • Greater than $90,000 in allowable amounts billed to Medicare
 

Submission Decisions

Say you decide to participate in MIPS. There are two major decisions to be made before diving in:
 
Claims or Registry
a. Claims: Only small practices, of 15 or fewer providers, can submit via claims.  
 
  1. When a clinic is submitting via claims, they only need to report MIPS for Medicare patients and it is free for them to report. 
  2. MIPS information is sent out every time you bill an eval or a re-eval code, so if anyone makes a mistake, it cannot be fixed.
  3. NOTE: If filing claims, a clinic is required to report as individuals. 

b. Registry: Clinics of 15 or more providers are required to submit via the registry.  

  1. Registries have an additional cost to submit (which varies based on the registry and whether you submit individually or as a group.) Clinics submitting via registries are also required to report MIPS data for all patients of all insurances, with the exception of minors. 
  2. There is, however, an advantage to registries in that the registry keeps an eye on performance and will send quarterly reports to inform the clinic of how they are doing and to help guide your performance in the program. TheraOffice has a registry for 2020, if you would like information, we would recommend visiting www.theraoffice.com/registry/  

 

Individual or Group

a. Individual: Claims can only file as individuals, but registries can as well. When you are submitting as individuals, each NPI is taken into consideration and their progress is measured separately.

  1. You can pick and choose which providers are participating in the program. 
  2. The MIPS measures will show up in everyone’s documentation, that said, only the providers you indicate will be REQUIRED to fill out MIPS to be able to lock their note.

b. Group: When you submit as a group, your group NPI is used and everyone’s progress is measured together.

  1. This is useful when everyone will be submitting anyway, as it can be more affordable when using a registry, and also simpler to keep track of. 
  2. All providers must participate in the program.  Even new providers that you add in 2020.  This also allows them to receive the payment adjustment in 2022.  If reporting individually, new providers would not end up getting scored.

 

Reporting MIPS

MIPS reporting is based on the CPT codes charged, rather than the types of notes. Most commonly, these codes are the evaluation and re-evaluation codes, which will require you to fill out all available MIPS measures. However, there are some additional codes that will require you to fill out just a specific measure. If one of these codes is charged, the system will prompt you to fill out the relevant sections.

 

MIPS Features

There are a few measures available to report on in TheraOffice:
 
  • BMI: Must be measured in the office, you cannot just ask a patient for their height and weight. If their BMI is outside normal range, you must document a follow up plan to help them get into normal range. BMI only needs to be reported once a year and patients can be exempt and marked as ineligible if they are under 18, pregnant, or non-ambulatory.
  • Falls: If a patient is 65 years or older and has had 2 or more falls, they are considered a falls risk. If they are a falls risk, a provider must document a plan of care. In order for these measures to count toward the score, each participating provider will need a minimum of 20 patients who are a falls risk.
  • Diabetes: This measure is only available for TheraOffice registry customers. To be considered eligible, a patient must have a diagnosis code from their physician indicating that they have diabetes.
  • Medications: Proper documentation requires the medication name, dosage, frequency, and route of administration. Providers can also satisfy the requirements for this measure by scanning a list of medications to the patient’s file, as long as that list contains all 4 requirements.
  • Pain Assessment: Located under Functional Testing. Certain tests will assess a patient’s pain levels and impairment due to pain. Some tests will assess both pain and functional outcome assessments. This measure is being retired for 2020 but will remain available in the software for clinics retroactively filling out their notes.
  • Functional Outcome Assessment: Located under Functional Testing. Certain tests will assess a function and impairment. Some tests will assess both pain and functional outcome assessments.
  • Depression Screening: New for 2020. Required for all patients above the age of 12 who are not already diagnosed with depression or bipolar disorder. Many different types of screening available. Clinic will choose from QPP which they prefer to use, then will attest the result of that screening in TheraOffice. If the screening is positive for potential depression, the provider will document a follow-up plan.
  • Elder Maltreatment Screening: New for 2020. All patients 65 years and older. Many different types of screening available. Clinic will choose from QPP which they prefer to use, then will attest the result of that screening in TheraOffice. If the screening is positive, they will report it to local or state adult protective services and, in TheraOffice, document that it has been reported.
  • Dementia Assessment and Support: Two measures, new for 2020. These measures are available only via the registry and are to be performed on all patients, regardless of age, who are not already diagnosed with dementia. In TheraOffice, providers will attest to the assessment of dementia functional status at least once every 12 months. If the patient is assessed to be displaying signs of dementia, the provider must provide education and resources to the caregiver of the patient and attest to that process in TheraOffice.
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