Under the traditional Merit-Based Incentive Payment System (MIPS), there are four weighted performance categories that contribute to your total MIPS score. For this blog, we’ll be taking a closer look at the Quality Performance category, which has an impact of between 30 – 85% on your total MIPS score, depending on your practice size and patient population.
Meeting the requirements of the Quality Performance category is essential to optimizing your final MIPS score, avoiding the payment penalty of up to 9%, and ensuring eligibility for a performance bonus. While the category has the largest impact on the MIPS score, participants often score lowest in this area due to the complexity and variability of the reporting requirements.
The CMS Quality Measure specifications, which are updated annually, define specific reporting documentation required to meet the performance of the measure and code the measure:
Performance Met – Measure requirements were met and documented in final report.
Performance Not Met – Measure requirements were not documented in final report.
Exceptions – Reasons for not meeting measure requirements are documented in final report.
The quality score of each measure is established by calculating the percentage of cases where the measure’s performance was met versus those where it was not met. Often, a case is coded “Performance Not Met” because the final report did not contain the specific measure documentation required to code “Performance Met.” Applying the code “Performance Not Met” to even just one measure can negatively impact your score.
For example, in the measure below, based on the historical benchmarks, only cases coded “Performance Met” 100% of the time will receive a maximum score, provided data completeness and minimum case requirements are met. Proper documentation of the performance, met or not met (including reasons why), is imperative for avoiding a negative impact to your score.
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed.
Report dictation requirements to code:
Performance Met: Final report for bone scintigraphy study includes correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT) corresponding to the same anatomical region in question (3570F)
Exception: Documentation of system reason(s) for not documenting correlation with existing relevant imaging studies in final report (e.g., no existing relevant imaging study available, patient did not have a previous relevant imaging study) (3570F with 3P)
Performance Not Met: Bone scintigraphy report not correlated in the final report with existing relevant imaging studies, reason not otherwise specified (3570F with 8P)
To optimize their MIPS Quality score, radiologists should review the CMS Quality Measure specifications each year for each measure to ensure sufficient understanding of the required report documentation and to help minimize the number of cases coded “Performance Not Met.”
Avoiding the 9% payment penalty will continue to be an uphill battle for many radiology groups. When the MIPS program was first implemented, the goal was to achieve the highest score possible and obtain a potential positive payment adjustment on Medicare claims. As the program evolved and requirements increased, the goal transitioned from getting a positive payment incentive to avoiding a negative payment adjustment.
Listed below are additional issues radiologists should be aware of which could impact their Quality score, including:
Benchmarked vs. Non-Benchmarked Quality Measures
For benchmarked measures, the scoring range is 1 to 10, eliminating the 3-point floor. Non-benchmarked measures will receive zero points even if data completeness is met, while new measures without a benchmark will continue to be scored at a minimum of 7 points for the first year and a minimum of 5 points in their second year.
70% of Data Completeness
The percentage of eligible cases that must be reported on (data completeness) remains at 70% for 2023. However, in 2024 and 2025, it will increase to 75%. When the data completeness isn’t met, the measure will receive zero points.
Minimum Requirements of 20 Eligible Cases Per Measure
For the measure to be scored against a national benchmark, at least 20 applicable cases must be reported, otherwise the measure will receive zero points.
Small Practice Bonus Points and Scoring
CMS defines a “small practice” as a practice with 15 physicians or less. For those who receive this special status, the 3-point floor will remain for measures without a benchmark or that do not meet the minimum case requirement, in addition to six bonus points added to the quality score.
For additional information on issues impacting medical reimbursement and billing, subscribe to XiFin’s Beyond Billing blog.
Access the printable guide, which details the required report documentation for the most common radiology MIPS Quality measures.
Review the 2023 Quality Payment Program Final Rule Resources. Located on the CMS QPP Resource webpage, the link to the 2023 Program includes a fact sheet, comparison tables, and FAQs.
Published by XiFin
