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Changes to Medicare Quality Payment Program Under 2019 Medicare Physician Fee Schedule Proposed Rule

by Bill Finerfrock on July 30, 2018 at 6:14 PM


On July 12th, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule (PFS) proposed rule. Numerous changes to the Quality Payment Program have been proposed under the 2019 PFS that impact aspects of the Merit-based Incentive Payment Program (MIPS) including eligibility, performance measurements, and quality metrics.

Below is a brief description of the proposed changes and what they could mean for you.

Update to MIPS Performance Threshold

For the 2019 MIPS reporting year, CMS is proposing to increase the MIPS performance threshold from 15 to 30 points. Eligible clinicians (EC) must meet the performance threshold to avoid up-to a 7 percent negative payment adjustment in 2021. ECs can earn up-to a 7 percent payment positive payment adjustment based on their performance. ECs who earn a MIPS Composite Performance Score of 80 points will be eligible for additional bonuses from a separate pool of bonus money.

Expansion of Eligible Clinician Provider Types

The proposed rule adds Physical Therapists, Occupational Therapists, Clinical Social Workers and Clinical Psychologists to the list of clinicians eligible for MIPS. The current list includes Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialist and Certified Registered Nurse Anesthetists.

Addition to Low-volume Provider Threshold and Opt-in Mechanism

ECs who fall below the low-volume provider threshold are exempt from MIPS reporting and payment adjustments. For 2018, ECs who had $90,000 or less in Medicare Part B revenue or who treated 200 or fewer Medicare beneficiaries were exempt from MIPS.

For 2019, CMS is proposing to maintain the 2018 threshold requirements, of Medicare Part B revenue ($90,000) and Medicare beneficiaries (200), but is adding another basis for MIPS exemption - providing 200 or fewer Medicare covered services.

Falling below any of these three parts of the threshold definition would exempt an EC from MIPS reporting in 2019.

However, CMS is proposing to allow ECs who fall below one or two of the three options to voluntarily opt-into MIPS. This opt-in mechanism is in response to the comments of many stakeholders who advocated for an opt-in mechanism.

Changes to MIPS Performance Categories

CMS is proposing to change the name of the Advancing Care Information category to Promoting Interoperability.

CMS is also proposing to reduce the weight of the Quality category from 50 percent to 45 percent and increase the weight of the Resource Use category from 10 to 15 percent. The Promoting Interoperability and Clinical Practice Improvement Activities categories would maintain their current weight of 25 percent and 15 percent respectively.


2018 Weight

Proposed 2019 Weight




Clinical Practice Improvement Activities



*Promoting Interoperability



Resource Use



*Previously Advancing Care Information


CMS is also providing ECs with the flexibility to use multiple reporting mechanisms to report data within each MIPS reporting category. For example an EC might report Promoting Interoperability by logging in and attesting the requirements were met, while it may be easier to report Clinical Practice Improvement Activities and Quality using a direct computer-to-computer transmission of data through an API already incorporated into their typical workflow.

Facility-Based Measures Scoring Option for the 2021 MIPS Payment Year

In another important update, CMS proposes that MIPS ECs who provide 75 percent or more of their covered services in emergency departments or as hospital inpatient services are allowed to report a new, “facility-based” set of quality measures. To determine if ECs qualify for facility-based measures CMS uses POS codes 23 for emergency departments and 21 for inpatient.

CMS is also proposing to add on-campus outpatient hospital services (POS code 22) to the list of services for the facility-based measurements. Additionally, CMS would require that a clinician must have at least a single service billed with the POS code used for the inpatient hospital or emergency room to qualify for the facility-based measure set.

New MIPS Quality Measures

CMS is proposing to add 10 new quality measures to the MIPS Quality Performance category for the 2019 reporting year, as well as modifications to existing measures. The new and modified measures are described in detail in Appendix 1 of the proposed rule (Page 1197).

New MIPS Improvement Activities

In addition to the new quality measures, CMS is proposing to add six new improvement activities to the Clinical Practice Improvement Activity (CPIA) MIPS performance category for 2019. CMS is also proposing to modify five existing activities and remove one existing activity. The new, modified and deleted activities are described in detail in Appendix 2 of the proposed rule (Page 1464).

Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

Finally, CMS is proposing a new demonstration that allows ECs who participate in risk-bearing Medicare Advantage plans to be exempt from MIPS reporting and payment adjustments. This proposal is in response to stakeholder feedback that capitated Medicare Advantage plans should be considered Alternative Payment Models (APM).

CMS will be accepting comments on the proposed rule until September 10, 2018. We will continue to keep you informed as updates become available.

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This post was written by Bill Finerfrock

Bill Finerfrock is a consultant at Intermedix and is president of Capitol Associates (CAI). Finerfrock specializes in health care financing, health systems reform, health workforce and rural health. Finerfrock has worked in and with the U.S. Congress and Federal agencies on health policy matters for nearly 40 years