MIPS 2020: An Overview

By: Cheryl “Chae” Dimapasoc, PT, DPT;  OptimisPT Director of Implementation and Compliance

Most therapists are not required to report MIPS for the 2020 performance period, but many are choosing to “opt-in” to try and receive a portion of the “up to 9% payment incentive”, where the adjustment will occur in 2022.  Many are choosing to participate since, other than the potential MIPS payment adjustment, there will be no increase to the Medicare fee schedule for therapists for the next few years.  Many therapists wonder, however, is it worth it?

PTs, OTs, and SLPs are MIPS eligible clinicians, but are only required to report if he/she meets all three of the low-volume threshold aspects.  You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments of the MIPS determination period, you:

• Bill more than $90,000 for Part B covered professional services, and
• See more than 200 Part B patients, and
• Provide more than 200 covered professional services to Part B patients.

How is Eligibility Determined?

The Centers for Medicare & Medicaid Services (CMS) reviews past and current Medicare Part B Claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each Performance Year.  Each review, or “segment”, looks at a 12-month period.  Data from the first segment is released as preliminary eligibility.  Data from the second segment is reconciled with the first segment and released as the final eligibility determination.  This is important to note because during the 2019 performance period, some therapists checked their eligibility in April 2019, and they were not required to report, but upon checking in October 2019, they found that based on the 2nd segment, they WERE required to report for the 2019 performance period.  If you are on the bubble at the beginning of the year, this is important to remember because it will be too late to start reporting MIPS later in the year as you will not have time to receive an acceptable score.

Therapists providing outpatient/Medicare Part B services in a hospital, skilled nursing facility, rehab agency, or other institutional setting (i.e., those billing on a UB-04) are not eligible to participate in MIPS.

Rehab therapists will report 2 out of the 4 MIPS categories.  These include Quality Measures and Improvement Activities.  The therapist will earn a MIPS score ranging from 0-100.  

The most notable changes for the MIPS 2020 Performance period:

• PT/OT measure set changes (added and deleted measures)
• Quality reporting data completeness increased to 70%
• For group reporting, 50% of providers in the group are now required to perform Improvement Activities
• MIPS scoring threshold increased to 45 points

Scoring

CMS finalized a performance threshold of 45 points for the 2022 payment year (the 2020 performance year), and 60 points for 2023.  The “additional performance threshold” – or exceptional performance benchmark – will be 85 points for both payment years 2022 and 2023.

The maximum payment adjustment for 2022 is +/- 9%.  The MIPS program remains budget neutral such that incentives are paid based on penalties incurred.  Incentive percentages are based on a “scaling factor” that increases as the number (and amount) of penalties increase. More MIPS eligible clinicians with scores above the performance threshold means the scaling factor decreases; more clinicians below the performance threshold means the scaling factor increases.  As the scaling factor increases, the incentive percentage increases.

For example, if the scaling factor is 0.395, a clinician who scores 100 points in MIPS would receive a 3.95% adjustment, along with the exceptional performance bonus (which is paid from additional dollars).

Quality Measures

Per CMS, the definition of Quality Measures for the MIPS program is “the performance category which measures health care processes, outcomes, and patient experiences of their care.”   We have included a chart listing the Quality Measures that are relevant to rehab therapists.  This chart indicates which discipline can report the measure and which method of submission can be used to report each measure.  PTs and OTs are required to submit 6 Quality Measures and SLPs are required to submit 4 Quality Measures.  Each Quality Measure must have been performed on at least 20 patients and you must meet 70% data completeness.

MIPS measure #	MIPS measure name	PT	OT	SLP	Claims	FOTO	PTOR
126	Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation	X			X		X
127	Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear	X			X		X
128	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up	X	X		X		X
130	Documentation and Verification of Current Medications in the Medical Record	X	X	X	X		X
134	Screening for Clinical Depression and Follow-Up Plan	X	X		X		X
154	Falls Screening	X	X		X		X
155	Falls Plan of Care	X	X		X		X
181	Elder Maltreatment Screen and Follow-Up Plan	X	X	X	X		X
182	Functional Outcome Assessment	X	X	X	X		X
217	Functional Status Change for Patients with Knee Impairments	X				X
218	Functional Status Change for Patients with Hip Impairments	X				X
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	X				X
220	Functional Status Change for Patients with Low Back Impairments	X				X
221	Functional Status Change for Patients with Shoulder Impairments	X	X			X
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	X	X			X
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention		X	X		X	X
282	Dementia: Functional Status Assessment	X	X		X		X
288	Dementia: Education and Support of Caregivers for Patients with Dementia	X	X		X		X
478	Functional Status Change for Patients with Neck Impairments	X				X
FORCE 21	Review of Pain Status Assessment for Patients with Osteoarthritis	X					X
IROMS 11	The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported.	X					X
IROMS 12	The proportion of patients failing to achieve MCID of two (2) points or more improvement in the NPRS change score for patients with knee injuries treated during the observation period will be reported.	X					X
IROMS 13	The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.	X					X
IROMS 14	The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.	X					X
IROMS 15	The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported.	X	X				X
IROMS 16	The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported.	X	X				X
IROMS 17	The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported.	X					X
IROMS 18	The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported.	X					X
IROMS 19	The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported.	X	X				X
IROMS 20	The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported.	X	X				X

Visit the QPP Website for more information regarding Quality Measures.

Improvement Activities

Per CMS, this performance category measures participation in activities that improve clinical practice.   Here is some important information regarding Improvement Activities:

• They comprise 15% of the final MIPS score
• Each activity needs to be performed for 90 consecutive days (1 quarter) 
• If your practice participates in Group Reporting the activity(ies) need to be performed by 50% of those on staff; be sure to save documentation for potential auditing 
• Attest to the activity prior to 2020 data submission 
• Full credit requires 40 points of activities: 
  • 2 high, 1 high +2 medium, or 4 medium 
• Those designated as a Small Practice get double credit and will only need 1 high or 2 medium weighted activities.  You can check your designation by going to the QPP Website.

Visit the QPP Website for more information and a full list of eligible activities: https://qpp.cms.gov/mips/improvement-activities

If you are going to report MIPS, it is highly recommended that you consider a Qualified Clinical Data Registry (QCDR) versus submitting the measures via the claims process.  OptimisPT is interfaced with both FOTO’s QCDR and APTA’s Physical Therapy Outcomes Registry (PTOR). The benefits of using a QCDR include:

• QCDRs can develop and/or submit unique measures to CMS for CMS approval.  These measures are called QCDR measures.
• Eligible clinicians may be able to earn bonus credit in multiple performance categories. The clinicians using a QCDR receive benchmark information, so they can see how they are performing in comparison with their peers.
• QCDRs are required to provide quarterly feedback reports to their participating clinicians, which provides the clinicians the opportunity to make more rapid changes to improve quality of care and the ability to make corrections prior to submission.

In response to the Covid-19 health emergency, CMS has announced the ability for clinicians who have been significantly impacted by the pandemic to submit an Extreme and Uncontrollable Circumstances application.   The clinician will have to provide evidence and justification as to how their practice was impacted.  If the application is approved, this will allow those clinicians to reweight any or all of the MIPS performance categories.  For more information on the application process and this program, please visit the MIPS 2020 QPP Exceptions Page.  Other than this exception process, there has been no other published change to MIPS requirements for 2020 secondary to the pandemic, at the time of publication.  Having said that, now is the time to make sure you are collecting your data as necessary before it is too late.

There are many factors that rehab therapists need to consider when deciding if they will report MIPS or not.  If you are required by CMS to report, you have no choice, but for those clinicians not required, you may be trying to decide whether to Opt-In or not.  What you really need to look at is the return on investment (ROI).  How much time, effort and money would be involved to report the measures?   If you are classified as a small practice, with less than 15 providers, you could easily include your MIPS Quality Measures on your claims. However, claims submission does not allow for the status checks available when using a QCDR. These updates can be extremely beneficial to allow your clinical staff to adjust and improve their measure intake prior to submitting the data and could help to improve your score, but an extra cost will be incurred for the use of a QCDR.  In addition, 50% of your clinicians will need to perform Improvement Activities for 90 consecutive days.   These activities generally do not incur large monetary costs, but they can cost time.  If you have an EMR, like OptimisPT, features already included in the software may help you to complete the Improvement Activities.  Taking all of this information into consideration, you will need to decide (1) if you feel your clinicians can perform well on MIPS, and (2) will the potential of up to 9% payment incentive be worth the extra time and/or money spent to report MIPS measures.  

If you are considering reporting MIPS for the 2021 performance period, it is highly recommended that you begin “practicing” by creating your MIPS workflow and including MIPS measures in your documentation by Q4 of 2020.  This will allow you to “hit the ground running” in 2021, increasing the likelihood of obtaining a good score.