Part 2 – MIPS: How Radiology Scores are Calculated

MIPS composite performance score
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MIPS: How Radiology Scores are Calculated

MIPS Series: part 2 of 4

By:

  • Barbara Rubel, MBA, FRBMA, MSN Sr. VP, Marketing and Client Services
  • Claudia Murray, RCC, MSN Sr. VP, Regulatory Affairs and Corporate Compliance Officer

Composite Performance Score (CPS) 

MIPS is all about a clinician’s Composite Performance Score (CPS).  The CPS determines the applicable payment adjustment under the Medicare Physician Fee Schedule and is calculated by a clinician’s performance in each of four performance categories:

  • Quality (40%)
  • Cost (20%)
  • Promoting Interoperability (25%)
  • Improvement Activities (15%)

Virtually all radiology groups are exempt from Promoting Interoperability (the EMR component of the program) and that 25% is automatically reweighted to Quality.  Radiology groups with Interventional Radiology procedures and Evaluation & Management visits (especially those with mid-level practitioners) will likely be impacted by Cost, which has risen to 20% of the CPS[1].  Exhibit A provides an illustration of how the performance categories are weighted.

MIPS Performance category weightings chart

Improvement Activities

Improvement Activities (IA) are fulfilled through attestation and at least 50 percent of the group must perform the same activity for 90 consecutive days [2] to satisfy this category. 

Challenges in Quality Scores

Quality is where radiologists have challenges.  To earn 100 percent of the Quality score, a group must earn 60 quality points. 

Clinicians may submit an unlimited number of measures; however, CMS will only score the highest earning six measures.  A maximum of six bonus points is available and bonus points are awarded for reporting high priority and outcome measures.  The first high priority or outcome measure reported does not earn a bonus point as CMS’ view is this is a requirement.  That said, if you report more than six high priority or outcome measures, the maximum bonus points can be earned.  

The following assumes Promoting Interoperability and Cost are re-weighted to Quality and illustrates total points earned:

Measure #Max Point ValueHP Bonus Points Total Points
2251010 *
145718
147718
19577
360718
43677
TOTAL45348

Total points of 48 are divided into the 60 points that are available = .80 * .85 (Quality = 85%) = 68 Quality Category Points.  Add 15 points for Improvement Activities (IA) and the total CPS = 83 points, which is two points below the 2021 Exceptional Performance Threshold of 85. 

In 2022, CMS has proposed to increase the Exceptional Performance Threshold to 90.  This is a perfect illustration of how a practice can score 100 percent in Quality and still fall short of the Exceptional Performance Threshold.

Incidental Measures

There are three incidental measures a diagnostic practice may choose to report.  Two of these measures are more valuable; however, the documentation can be difficult as many radiologists are concerned about dictating “no additional imaging is needed” for liability reasons.

These incidental measures are:

  • #364: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines (10 points + 1 HP bonus point)
  • #405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions (10 points + 1 HP bonus point)
  • #406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients (7 points + 1 HP bonus point)

With three, 10-point measures plus three, 7-point measures, a practice can earn 51 points plus 5 bonus points for a total Quality point value of 56 divided into 60 = .93 * .85 = 79.33 Quality Category Points.  Add 15 points for IA and the total CPS = 94.33, which does qualify for the Exceptional Performance Bonus in 2021. 

Additional Interventional Radiology Reporting

Practices that perform even limited Interventional Radiology procedures may also report:

  • #76: Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections (7 points + 1 HP bonus point)
  • #421: Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal (no benchmark [4] – 3 points)
  • #355: Unplanned Reoperation within the 30-Day Postoperative Period (10 points + 2 Outcome bonus points) – this measure may be devalued by CMS in 2020
  • #357: Surgical Site Infection (SSI) (10 points + 2 Outcome bonus points) – this measure may be devalued by CMS in 2020
  • #409: Clinical Outcome Post Endovascular Stroke Treatment (no benchmarks – 3 points)
  • #413: Clinical Outcome Post Endovascular Stroke Treatment (no benchmarks – 3 points)

Evaluation and Management Visits Reporting

Practices that perform Evaluation & Management visits may report:

  • #21: Perioperative Care: Selection of Prophylactic Antibiotic -First OR Second-Generation Cephalosporin (7 points + 1 HP bonus point)
  • #23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) (7 points + 1 HP bonus point)
  • #47: Advance Care Plan (10 points)
  • #110: Preventive Care and Screening: Influenza Immunization (10 points)
  • #111: Pneumococcal Vaccination Status for Older Adults (10 points)
  • #112: Breast Cancer Screening (10 points)
  • #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (10 points)
  • #130: Documentation of Current Medications in the Medical Record (7 points + 1 HP bonus point)
  • #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (10 points)
  • #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (10 points)

A comment on reporting E&M measures is they do potentially expose the practice to patient attribution under the Cost Performance Category.  

[1] Cost will likely not be attributed to Radiology groups that are primarily diagnostic with little to no interventional radiology.

[2] The 90-day period may vary by clinician.

[3] Measure 225 is a high priority measure but is not awarded a bonus point, per the information above.

[4] To establish a benchmark, a measure must be reported to CMS by a minimum of 20 practices or eligible individuals. 

* Measure 225 is a high priority measure but is not awarded a bonus point, per the information above.

MIPS Article Series

This article is #2 of 4 in our MIPS series. Be sure to check out the rest of the articles in the series: 

Barbara Rubel MBA, FRBMA Senior Vice President, Marketing & Client Services

Barbara Rubel MBA, FRBMA Senior Vice President, Marketing & Client Services

Barbara has been a leader with MSN Client Services since 1998. Her extensive background in strategic planning, market research, healthcare marketing and managed care negotiations provide a wealth of information to support MSN Clients.

Barbara has also been highly involved in industry organizations, serving as President of the Radiology Business Management Association (RBMA), the Georgia RBMA, and the Florida RBMA. In addition, she chaired the influential RBMA Federal Affairs Committee and the RBMA Technology Task force and was a member of the RBMA Data Committee. Her work on behalf of radiology has earned her the RBMA Special Recognition Award (2010), the RBMA Global Achievement Award (2013), and she is a Fellow of the RBMA.

Claudia Murray, RCC Senior Vice President of Regulatory Affairs Executive,  Director of Quality Payment Programs

Claudia brings an extensive background in Medicare regulations, law and billing processes having spent more than 20 years with the Medicare program in various roles. Prior to joining MSN Healthcare Solutions as their full-time compliance officer, Claudia headed a small consulting firm specializing in radiology and other hospital-based specialties. She consulted with MSN for 15 years in designing, implementing and advising on their compliance programs.

Currently at MSN, Claudia is responsible for the myriad activities for HIPAA and corporate compliance as well as the Quality Payment Programs, bringing her full circle to CMS regulations and programs.

Claudia Murray RCC Senior Vice President of Regulatory Affairs Executive Director of Quality Payment Programs