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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.

Capturing data via Medicare claims illustrates a deeper picture of the quality of care a patient is receiving. 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 assigned 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.

  • 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.


[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

About Alex Dighero


Alex is a consultant and account manager for MIPS-related matters, including pathology sales support, MIPS services sales, and delivery of MIPS services. She is a certified compliance technician with the American Association of Healthcare Administrative Management. She has an MBA in health care administration from Cleveland State University.

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