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Collection period for MIPS Year 3 started on January 1st, 2019 and will end on December 31, 2019. By March 31 2020, eligible clinicians need to submit MIPS Year 3 (2019) data for the Centers for Medicare and Medicaid Quality Payment Program (CMS QPP). 2019 data directly impacts the physician fee schedule payments for the year of 2021. 

Participation of eligible clinicians in MIPS Year 1 (2017) exceeded CMS’ goal of having 90 percent of eligible clinicians’ participation. MIPS Year 2 (2018) likely reached high levels of participation as well. 

In 2019, CMS expanded the types of clinicians who are subject to participation in MIPS, and implemented other updates. This blog post summarizes some of these changes and provides an overview on how WoundReference can support eligible clinicians and groups participating in MIPS. For more information on MIPS Improvement Activities see topic "MIPS in Wound Care and Hyperbaric Medicine - Improvement Activities"For an update on Quality in wound care see topic "Quality in Wound Care".

What is MIPS ?

CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program (QPP), which rewards value and outcomes in one of two ways: 

  • Merit-based Incentive Payment System (MIPS). Continue reading for more information
  • Advanced Alternative Payment Models (APMs). For more information on APMs visit the QPP website

Under MIPS, eligible clinicians are required to submit data across 4 categories (Quality, Promoting Interoperability, Improvement Activities and Cost). A final score (0-100) is calculated from these 4 categories. Each eligible clinician or group’s final score is compared to a performance threshold. Final scores above the threshold receive a positive payment adjustment (bonus). The performance threshold for the 2019 performance period is 30 points. 

Some MIPS categories require data to be collected throughout the entire year of 2019.

However, if you have not started collecting data for 2019 yet, it is not too late to start now. Submitting some data is better than submitting no data.

How does MIPS affect payments to eligible clinicians? 

If you are required to participate in MIPS, you will earn a performance-based payment adjustment - up, down, or not at all - based on the 2019 data that you submit (or do not submit) by March 2020. Payment of 2021 will be affected.

If you don’t submit any 2019 data by March 2020, then you receive a negative 7% payment adjustment in 2021. Negative adjustment will increase in subsequent years to 9%. So for data collected in 2019, every $1 million that would be received from Medicare for services provided in 2019, you could lose $70,000. For services performed in 2020 you'd loose $90,000 for every $1 million.

How do I know if I am required to participate in MIPS? 

Starting in 2019, Medicare expanded the types of clinicians who are subject to participation in MIPS. Clinicians listed in table 1 who bill Medicare through the Medicare Physician Fee Schedule and meet certain criteria are required to participate:

Table 1. MIPS 2019 - Eligible Clinician Types
  • Physicians, including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry; osteopathic practitioners; and chiropractors
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • NEW: Clinical psychologists
  • NEW: Physical therapists
  • NEW: Occupational therapists
  • NEW: Qualified speech-language pathologists
  • NEW: Qualified audiologists
  • NEW: Registered dietitians and nutrition professionals

For eligible clinician types above, the quickest way to find out if a clinician meets participation criteria is by looking him/her up on the QPP Participation Status Tool. 

  • You will need your National Provider Identifier (NPI) and Associated Taxpayer Identification Numbers (TINs). When you reassign your Medicare billing rights to a TIN (e.g., TIN that belongs to a hospital or practice), your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination. 
  • If the provider is required to participate, determine if provider is considered “Facility-based”. Medicare's goal for measuring performance at the facility level is to reduce reporting burden for MIPS eligible clinicians who are facility-based. 

What are Medicare's criteria for participation in MIPS in 2019? 

  • Clinician needs to be an eligible clinician (see Table 1) AND:
    • Is enrolled in Medicare prior to January 1, 2019 AND
    • Does not become a part of an APM AND
    • Exceeds the low volume threshold 
      • What is the low volume threshold? Medicare looks at your Medicare claims from two 12-month segments, referred to as the MIPS determination period, to assess the volume of care you provide to Medicare beneficiaries. The two 12-month segments are: October 1, 2017 – September 30, 2018 and October 1, 2018 – September 30, 2019. You must participate in MIPS if, in both 12-month segments, you:
        • Bill more than $90,000 for Part B covered professional services/ segment AND
        • See more than 200 Part B patients/ segment AND
        • Provide 200 or more covered professional services to Part B patients/ segment (NEW)
  • If you’re not required to participate as an individual, you may still be required to participate (and receive a payment adjustment) if:
    • Your practice chooses to participate as a group
    • You are part of an approved virtual group
    • You participate in a type of APM called a MIPS APM

How does Medicare determine if an eligible clinician is a facility-based provider? 

  • The eligible clinician is a facility-based provider if he/she:
    • Billed at least 75 percent of your covered professional services in a hospital setting, AND
    • Billed at least one service in an inpatient hospital or emergency room AND
    • Can be attributed to a facility with a Hospital Value Based Purchasing score.

How do I get started?

  1. Determine eligibility for QPP: Check if the provider is required to participate by using the QPP Participation Status Tool.
  2. If participation is required, determine if provider is facility-based or not. The QPP Participation Status Tool should indicate that.

For non-facility-based eligible clinicians

  1. Start by focusing on the Quality performance category. Why? The Quality performance category has a 12-month performance period, so you’ll want to start collecting your performance data now.

    1. Visit the 2019 Quality Requirements page and explore the 2019 measures on the QPP website, and also on US Wound Registry

  2. Learn about the Promoting Interoperability category and explore measures.

  3. Learn about the Improvement Activities category and explore measures.

  4. Learn about Cost performance and explore measures.

  5. Check out timeline and deadlines for 2019 data submission. (Submission may not be straightforward, so plan how each data set will be submitted ahead of time)

For facility-based eligible clinicians

  1. Quality and Cost may be reported through hospital, via the Value Based Purchasing Program

  2. Learn about the Promoting Interoperability category and explore measures.

  3. Learn about the Improvement Activities category and explore measures.

  4. Check out timeline and deadlines for 2019 data submission. (Submission may not be straightforward, so plan how each data set will be submitted ahead of time).

Table 1. Summary of MIPS categories, submission requirements and collection period 

QualityPromoting InteroperabilityImprovement ActivitiesCost
Percentage of total score45%25%15%15%
Submission requirements

Submit collected data for at least 6 measures, or a complete specialty measure set; and

  • One of these measures should be an outcome measure (or another high priority measure)

In addition, for groups of 16 or more clinicians who meet the case minimum of 200, the administrative claims-based all-cause readmission measure will be automatically scored as a seventh measure

Participants must submit collected data for certain measures from each of the 4 objectives measures - electronic prescribing, health information exchange, provider to patient exchange and provider to registry exchange (unless an exclusion is claimed). In addition to submitting measures, clinicians must:

  • Submit a “yes” to the Prevention of Information Blocking Attestation,
  • Submit a “yes” to the ONC Direct Review Attestation; and
  • Submit a “yes” for the security risk analysis measure

Participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2019)

  • 2 high-weighted activities, or
  • 1 high-weighted activity and 2 medium-weighted activities, or
  • 4 medium weighted activities
There is no data submission requirement for the Cost performance category. Cost measures are evaluated automatically through administrative claims data.
Collection period
12-month performance period (January 1 - December 31, 2019). The amount of data that must be submitted depends on the collection (measure) type.
For 90 continuous days or more during 2019
For 90 continuous days or more during 2019

How can WoundReference help eligible clinicians and groups perform well in MIPS? 

  • Quality category: WoundReference provides clinical algorithms/pathways that naturally highlight quality measures that clinicians can more easily meet in wound clinics. By following the algorithms and protocols, not only clinicians can perform well in the MIPS Quality category, but also practice evidence-based wound care.
  • Cost category: this category will continue to play a larger role in determining eligible clinician and group’s final score. WoundReference’s content and tools are designed with cost-effectiveness in mind. Tools such as the Formulary Module enable clinics to smoothly set up a local wound dressings formulary and save in inventory/supply costs. Another example is WoundReference’s Telehealth Conferencing tool, which allows efficient use of time for clinicians and patients. 
  • Improvement Activities category: And last but not least, just by using WoundReference’s decision support protocols and tools eligible clinicians and groups can easily meet the number of measures required in the Improvement Activities category. See topic "MIPS in Wound Care and Hyperbaric Medicine - Improvement Activities".

More topics on MIPS will be published soon. To find out more about how WoundReference can help clinicians perform well in MIPS, contact us

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