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There are four categories to the 2018 MIPS program: quality, promoting interoperability (formerly advancing care information), improvement activities, and the cost category. Though seemingly new to the program for 2018, the cost performance category was being tracked in 2017. However, it did not contribute to your MIPS score. This year the cost category will be scored and is worth 10 percent of your final score.

The cost category score is determined solely from data from Medicare claims. Data from Medicare claims can be used to better measure the quality of patient care. After all, the goal of the MIPS program is to increase the quality of care (and its purported outcomes) while being vigilant of our spending. According to CMS, claims data can be used to identify events such as readmissions, complications, and hospitalizations that would not otherwise be readily available through typical MIPS reporting. Moreover, this insightful data requires no extra reporting burden on behalf of the clinician and/or practice; CMS will use Medicare claims to calculate the category score.

What you will be scored on:

For performance year 2018, clinicians’ cost performance is based on two measures: 1. Total Per Capita Cost (TPCC) and 2. Medicare Spending Per Beneficiary (MSPB).

Total Per Capita Cost (TPCC)

This measure is the sum of all Part A and B Medicare costs during the reporting period. A Medicare beneficiary can be assigned to your TIN-NPI if you delivered a primary care service to them during the performance year. In this context, primary care services include evaluation and management services rendered in office and other non-emergency and non-inpatient settings, in addition to initial Medicare visits and annual wellness visits.[1] The beneficiary will be attributed to whomever delivered the most primary care services. Specialists are not excluded from this measure! A patient who has not seen a PCP during the year (but was provided with a primary care service[2] by a specialist) will be attributed to the non-PCP.

To determine if a beneficiary will be attributed to you under the TPCC measure, you can look at this flowchart.

Medicare Spending Per Beneficiary (MSPB)

This measure is based on what Medicare pays during an “MSPB” episode, which is the time directly before (3 days), during, and after (30 days) a patient’s hospital stay. This includes all Part A and Part B claims and is attributed to the clinician rendering the most Part B services during the admission.

To determine if a beneficiary will be attributed to you under the MSPB measure, you can look at this flowchart.

How your score will be determined:

You will be scored 1-10 points for each measure, resulting in 20 possible points.

If only one cost measure is applicable to you or your practice, only that measure will be used to determine your cost category score.

No action on your part is required.  CMS will calculate your score based on the claims submitted by Medicare Part A and Part B providers.   If you or your practice does not meet the case attribution minimum (20 cases for TPCC measure or 35 for MSPB measure), you will not be measured on the cost category.  In calculating the MIPS Final Score, the cost category will be reweighted from 10% to zero, and the quality category will be increased 10%  from 50% to 60%.


[1] CMS, “2018 Merit-based Incentive Payment System (MIPS) Cost Performance Category Fact Sheet

[2] Primary Care Services* (CPT):99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99347, 99348, 99349, 99350, 99495, 99496, 99490, G0402, G0438, G0439, G0436

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