2023 MIPS – Examining How Pathology Scores Are Calculated

  • Director of Anatomic Pathology Development

In the 2023 Quality Payment Program (QPP) final rule, there were minimal changes to the traditional Merit-Based Incentive Payment System (MIPS). The final rule focuses on further refining MIPS Value Pathways (MVPs) implementation. However, there are no pathology-related MVPs at this time. Therefore, the majority of pathologists will continue to participate under the traditional MIPS program.

Two changes under the 2023 MIPS program include:

Removal of 3-point bonus floor.

CMS removed the 3-point scoring floor for large practices, meaning measures that previously were worth 3 to 7 points, could be worth as little as 0 points. The three-point bonus floor remains in place for small practices.

New QPP pathology measure.

A new measure, which was previously only available through the CAP Pathology Registry, was added to the CMS QPP pathology specialty set. 

Measure Title: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma.

Description: Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.

In 2023, the MIPS performance threshold will remain at 75 points, and participants will continue to receive up to a 9% negative payment adjustment for not meeting the performance threshold.  

CMS is maintaining the MIPS performance category weights in 2023 and the performance category redistribution policies for small practices (15 or fewer clinicians). 

While there were minimal changes to the program, the removal of the 3-point scoring floor will have a significant impact. Avoiding a potential 9% payment penalty will continue to be an uphill battle for many pathology groups. When the program was implemented, the goal was to achieve the highest score possible and obtain a potential positive payment adjustment on Medicare claims. As the program evolved, the goal transitioned from getting a positive payment incentive to avoiding a negative payment adjustment.  

The key to avoiding a negative payment adjustment is understanding the formula CMS utilizes to calculate MIPS scores and what factors can impact that score. With that knowledge, pathologists can make proactive decisions to maximize their scores in 2023. 

CMS Improvement Activity Score

Scoring Formula:

At the end of the program, participants are required to “attest” to having performed an improvement activity for 90 continuous days. To receive full credit, 40 points, pathologists must report on one high-weighted activity or two medium-weighted activities.

For non-patient-facing physicians, the number of points available for each improvement activity is doubled. Therefore, for pathologists, medium-weighted activities are awarded 20 points and high-weighted activities are awarded 40 points. 

A detailed listing of each improvement activity along with the activity objective, weight, and validation documentation, is available on the CMS QPP website. The list of approved 2023 Improvement Activities will be released in January 2023 by CMS. 

Quality Score

Scoring Formula:

Quality is where pathologists have the most challenges maximizing their scores because several factors impact the score received on each measure. Due to the complexity and variability of the reporting requirements for each quality measure, participants often score lowest in this performance category because they may not fully understand the issues impacting the score.

Listed below are the factors impacting the quality score.

  • 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.
  • Benchmarked vs. Non-Benchmarked Quality Measures – The scoring range for benchmarked measures is 1 to 10, eliminating the 3-point floor. Non-benchmarked measures will receive zero points even if data completeness is met. 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. 
  • Minimum Requirements of 20 Eligible Cases Per Measure – Must report on at least 20 applicable cases for the measure to be scored against a national benchmark.   Measures with fewer than 20 applicable cases will receive zero points. 
  • Small Practice Bonus Points and Scoring – Special status is provided to physicians with 15 or fewer physicians, which is defined as “small practices” by CMS. For small practices, the 3-point floor will remain for measures without a benchmark or that do not meet the minimum case requirement. Small practices will also receive six bonus points awarded to the quality score.
  • Coding a Measure Performance Not Met – Under Quality, pathologists are scored based on how well they met the performance of the measure. The performance of each measure is defined in CMS measure specifications released each year that outline applicable cases and reporting documentation required to meet the performance of the measure. Based on the final report documentation, a case is either coded as "Performance Met, Performance Not Met, or Excluded. 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 one measure can negatively impact your score.
  • Topped-Out Measures Worth 7 out of 10 Points – Six measures under the CMS QPP Pathology Specialty Set remain topped-out at 7 points but are still scored on a 10-point scale. The College of American Pathologists has measures available through their registry worth 10 points.

It is important to note that if a large practice reports on the six topped-out pathology CMS QPP quality measures, maximizes each measure, and receives full credit for improvement activities, the final score will total 74.5 points, which falls just below the required performance threshold of 75. Therefore, large practices may choose to utilize the CAP’s Quality Data Code Registry (QCDR), which allows reporting additional CAP pathology-specific measures worth up to 10 points.

Four Ways to Maximize Your MIPS Score

To summarize, listed below are four ways to help maximize your MIPS scores:

1. Analyze the three requirements impacting the minimum points awarded for each quality measure. If all three of the requirements below are not met, large practices will receive zero points for the measure and small practices will receive three points.

  • 70% data completeness
  • 20 Minimum Case Requirements
  • Measure has a Benchmark

2. Understand how coding Performance Not Met will negatively impact the quality score. Applying the code Performance Not Met to a case will negatively impact your score. Therefore, pathologists should include the required report documentation, defined by CMS, in the pathology report to avoid coding Performance Not Met.

3. Identify the maximum points available on each quality measure. Six measures under the CMS QPP Pathology Specialty Set remain topped-out at 7 points but are still scored on a 10-point scale. If reporting on CAP non-benchmarked measures, understand the number of points that can be achieved with that measure.

4. Attest to performing improvement activities. Attest to performing either one high-weighted or two medium-weighted activities to earn 40 points.

MIPS-participating clinicians should begin focusing on 2023 MIPS now and evaluate MIPS scores monthly. Most registry companies require annual registration and have a deadline of around June. In addition, tracking your MIPS score monthly allows clinicians to make informed decisions on maximizing performance in each category and taking steps to avoid a penalty.

For additional information on issues impacting medical reimbursement and billing including MIPS, subscribe to XIFIN’s monthly newsletter, The Billing Beat.

Additional Resources:

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.  

CAP Quality Payment Program for Pathologists: Located on the CAP website under Advocacy, this section includes additional information on CAP’s Pathologist Quality Registry, MIPS Quality Payment Program, and CAP QCDR registry-specific measures.

Published by XIFIN
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