The Cost Category is one of four performance categories and makes up 15% of your total QPP (Quality Payment Incentive Program) score, which rewards value and outcomes in one of two ways: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Alternative Payment Models.)
This performance category replaces the Value Based Modifier (VBM). The cost of the care provided will be calculated by CMS based on your Medicare claims.
MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. This performance category began counting towards your MIPS final score in 2018.
The 2019 Cost Performance Category period begins January 1st, 2019 and ends on December 31, 2019. The 2020 reporting period begins on January 1st, 2020 and ends March 31st, 2020.
|Performance Period Begins||Performance Period Ends||Reporting Period Begins||Reporting Period Ends|
Individuals, groups, and virtual groups that are small practices (15 or fewer NPIs) can submit their quality measures via Medicare Part B Claims throughout the 2019 Performance Year.
IMPORTANT NOTE: Anyone participating in MIPS as an individual, group, or virtual group, that does not have the small practice designation can no longer use this submission type as an option for your quality data reporting. To see if you have the small practice designation, visit the QPP Participation Look Up Tool. A small practice is defined as a group that has 15 or fewer clinicians (NPIs) billing under the group’s Taxpayer Identification Number (TIN). If you do not qualify for the small practice designation, you can learn more about how to submit here.
CMS will calculate these measures on behalf of all clinicians in the group—including those who are not eligible to participate in MIPS—using administrative claims data, provided the group meets the case minimums for the measures and benchmarks can be calculated for the measures.
All clinicians and groups will be evaluated on the same 10 cost measures if they meet or exceed the measures’ minimum case volume necessary for the specific measure to be evaluated and scored.
You will only be scored in the Cost Performance Category on measures for which a benchmark exists and your group meets the case minimum. If your group falls below the case minimum on all of the Cost measures, the 15% weight for the performance category will be reallocated to other performance categories.
CMS uses Medicare claims data to calculate cost measure performance.
|Measure Name||Measure ID|
|Elective Outpatient Percutaneous Coronary Intervention (PCI)||COST_EOPCI_1|
|Intracranial Hemorrhage or Cerebral Infarction||COST_IHCI_1|
|Medicare Spending Per Beneficiary (MSPB)*||MSPB_1|
|Revascularization for Lower Extremity Chronic Critical Limb Ischemia||COST_CCLI_1|
|Routine Cataract Removal with Intraocular Lens (IOL) Implantation||COST_IOL_1|
|Simple Pneumonia with Hospitalization||COST_SPH_1|
|ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)||COST_STEMI_1|
|Total Per Capita Costs (TPCC)*||TPCC_1|
A total of 10 cost measures are used to evaluate performance in the Cost performance category in the 2019 MIPS Performance Period. Two of the ten measures were used to evaluate performance in the 2017 and 2018 MIPS performance periods.
Beginning with the 2019 MIPS performance period, eight episode-based measures will also be used to evaluate cost. The eight episode-based measures that are now included in the Cost performance category for the 2019 MIPS performance period are included in the table below.
* Two measures from the 2017 and 2018 MIPS performance periods.
Final percentage of score can change if the measures’ minimum case volumes are not met. If there are not enough attributed beneficiaries for any of the ten measures to be scored, the Cost performance category percentage will be added to the Quality performance category. The score for each measure is weighted to determine final category performance percentage.
Cost measures are attributed at the individual (TIN-NPI) level. Although cost measures will be attributed to individual clinicians, CMS will assess cost measure performance at either the individual clinician level or group level.
For groups participating in group reporting in other MIPS performance categories, their cost performance category scores will be determined by aggregating the scores of the individual clinicians within the TIN. However, the method used to attribute beneficiary costs to MIPS eligible clinicians at the TIN-NPI level differs for each measure.
Measure achievement points are determined by comparing performance on a measure to a benchmark. Cost measure benchmarks are created using performance data from the performance period, rather than historical benchmarks.
If a measure can be reliably scored against a benchmark, it means:
Facility-based measure scoring will apply January 1st, 2019, beginning with the 2019 Performance Period, clinicians and groups eligible for facility-based scoring will be identified. These clinicians and groups may have the option to use facility-based measurement scores for their Quality and Cost Performance Category scores.
Facility-based measurement scoring will be used for your Quality and Cost performance category scores when:
The Low Volume Threshold is one of the criteria used to determine whether or not a clinician or group is required to participate in MIPS for the 2019 Performance Period.
More information on the low-volume threshold is here.
Risk adjustment accounts for patient characteristics that can influence spending and are outside of clinicians’ control, such as clinical risk factors.
For example, for the elective outpatient PCI episode-based measure, the risk adjustment model may account for a patient’s history of heart failure.
All measures included in the Cost performance category are adjusted for clinical risk. However, the specific methodology used to risk adjust each measure varies. Methodological detail can be found in each measure’s specification documents here.
Risk adjustment should not be confused with the complex patient bonus, which is applied at the final score level and adjusts again for patient clinical complexity as well as some elements of social complexity.
MIPS eligible clinicians participating in MIPS APMs who are subject to the APM scoring standard are not assessed on the cost performance category.
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