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MIPS Essentials for 2020

Wednesday, November 20, 2019 9:00 AM

Billing, Coding & Compliance

Written by: Elizabeth Cifers, Laurie Brown

From left, Senior Consultant Laurie Brown and former Senior Consultant Elizabeth Cifers.

The end of 2019 marks the third calendar year since the Merit-based Incentive Payment System(MIPS) was integrated into ophthalmology practices across the country. Hopefully, you have avoided penalties and perhaps even received some level of bonus. Looking ahead to 2020, abiding by MIPS may prove more challenging, as the final score threshold is again ratcheting up from the prior year.  

Upcoming Changes  

When dealing with an ever-evolving program such as MIPS, the best way to ensure compliance is to stay well-versed on any changes going into effect each year. To help your practice be successful in 2020, we’ve highlighted some areas that will be updated. They include:  

Penalty avoidance performance threshold. This threshold is changing from 30 points to 45 points in 2020. It should remain achievable for most ophthalmic practices.  

Exceptional performance bonus threshold. This threshold for composite scores is changing from 75 points to 85 points. Additional bonus points will still be available to small practices (15 or less eligible clinicians) and/or practices with complex patients. These bonuses will be automatically applied.  

Cost performance. While the cost category weight of 15 percent will remain the same for 2020, ophthalmologists and optometrists will be excluded from the attribution of the Total Per Capita Cost measure. This measure has been burdensome to eye care providers since it holds them responsible for costs of care that they did not provide. If cost measures cannot be scored, performance categories will be reweighted.  
Improvement Activities (IA). The IA category contains additions, modifications and removal of activities, and you should review them for any adjustments you may need to make based on the IAs you have chosen to perform and report. Small practices will continue to receive full credit in this category by successfully submitting one high-weighted measure. Group participation, including virtual groups, has changed from being able to meet thresholds through one provider in the group in 2019 to a minimum requirement of 50 percent of providers in the group meeting thresholds for 2020. Of note, many ophthalmic practices are using the “Provide 24/7 Access” measure, and in 2020, at least 50 percent of those practice providers will need to have documentation of performing the measure.  

Data Completeness. Medicare Part B claims measures, Qualified Clinical Data Registry (QCDR) measures, and MIPS clinical quality measures (CQMs) and eCQMs have a 70 percent data completeness requirement for large practices (16 or more providers) in 2020; this is up from 60 percent in 2019. The data submitted should be representative of the MIPS eligible provider — in other words, not selectively submitted — to ensure the data accurately and completely represents the provider's performance. Small practices will continue to receive 3 points for any data submitted.  

Reimbursement effect. The penalty for underperformance will increase from 7 percent to 9 percent in 2020, as will the positive payment adjustment potential.  

Removal and changes to quality measures. The removal of two quality measures and changes to several measures used in ophthalmology are slated for 2020.  

The measures being removed are:  

  • Measure 192, Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures; and
  • Measure 388, Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)

The measures undergoing changes are: 

  • Measure 19, Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care — This will no longer be available for claims-based reporting;
  • Measure 191, Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery — A language change indicates the measure will be per eye, not per patient; and
  • Measure 385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery — A language change will exclude patients with a pre-operative visual acuity of 20/40 or better.

Staying the Same  

While each new year brings changes to the MIPS program, some aspects will remain the same. They include:  

Individual and group reporting. There will still be the option to report as individuals or groups, as well as the virtual group option. If you plan to use the virtual group designation, it needs to be declared to the Centers for Medicare & Medicaid Services (CMS) by Dec. 31, 2019. Group reporting still appears to be advantageous for most ophthalmology practices.  

Quality reporting. This must still be reported for a full 12 months without a 90-day option. Improvement Activities (IA) and Promoting Interoperability (PI) measures can still be reported for either (a) any 90-day period during the year or (b) the full year. 

Quality and PI categories. When reporting your activity data in 2020, you still need to use the 2015 certified electronic health record technology (CEHRT) version of your software.  

PI scoring. While scoring was made slightly more user-friendly in 2019, there are still minimum measures that must be met to ensure credit for this category.

Quality bonus scoring. The bonus scoring of the Quality category is unchanged for 2020, as it relates to improvement from past reporting (without penalty for underscoring compared to past performance).  

Audits. These are continuing, so it’s recommended you retain documents for at least six years (and 10 years for Office of Inspector General (OIG) audits).  

Targeted review of MIPS scores. This will continue in 2020, so if you disagree with your 2019 MIPS score, you can apply for a review within 60 days of the MIPS payment adjustment factor being released.  

Exception applications. These are still available, with applications for 2019 Promoting Interoperability Hardship Exception and the MIPS Program Extreme and Uncontrollable Circumstances Exception on the Quality Payment Program (QPP) website. They are due by Dec. 31, 2019.  

AAO’s IRIS Registry  

While there are a few platforms that offer MIPS program support, the American Academy of Ophthalmology (AAO)’s Intelligent Research in Sight (IRIS) Registry remains the preferred platform for most ophthalmic practices. Not only did IRIS greatly increase its ability to report quality measures in 2019, but it also continues to participate in testing measures to set threshold scores. Using these newer qualified clinical data registries (QCDR) measures for testing may earn you additional points. Perhaps most valuable, the IRIS Registry will, at the time of attestation, review your performance across all quality measures and submit the most advantageous score for you or your group. To learn more about why ophthalmic practices prefer the IRIS Registry, read our previous MIPS blog post 

Do the Best You Can  

After three years of implementation, MIPS remains manageable, and we encourage active participation. Our advice to clients this year remains the same from previous years: Participate with your best effort while staying aligned with your practice’s focus and activities. Generating sensible reporting should be just another operational practice — one that easily integrates into your mission to always do the best you can for your practice. 

NEED HELP? Contact Rose & Associates, a division of BSM Consulting, at 1-800-720-9667. Otherwise, learn more about MIPS at 

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