How important is the MIPS cost category to radiology?

By Richard Morris, contributing writer

March 19, 2018 -- The U.S. Centers for Medicare and Medicaid Services (CMS) threw a surprise into the Quality Payment Program (QPP) final rule for 2018 when it included the cost category as 10% of the Merit-Based Incentive Payment System (MIPS) final score for 2018 reporting. The QPP proposed rule issued a few months earlier stated that cost would be weighted as 0% for 2018 as it had been in 2017. So what does this mean for radiology?

How will adding the cost category affect the final score?

The cost category score will contribute 10% of the MIPS final score. The quality category is nominally 50%, improvement activities (IA) is 15%, and advancing care information (ACI) is 25%. Most radiologists will be exempt from ACI reporting, so its 25% will be shifted to quality, making quality worth 75%. Radiologists would expect to score very well on quality and IA, but now with cost in the mix its 10% contribution could bring down the total score for radiologists to the point where a positive adjustment is out of reach unless they can produce a high score in the cost category.

How will cost be evaluated?

Richard Morris
Richard Morris, director of value-based strategy at Healthcare Administrative Partners.

CMS will evaluate individual eligible clinicians (ECs) and group practices on two measures in 2018: Total Per Capita Cost (TPCC) for attributed beneficiaries and Medicare Spending Per Beneficiary (MSPB). The first measure will affect providers such as those in primary care and internal medicine. The provider who delivers the most office-based and noninpatient evaluation and management services to a patient is assigned that patient as a designated beneficiary. This provider could be a specialist, such as a cardiologist, if that specialist delivered more services than the patient's primary care physician.

Medicare Spending Per Beneficiary (MSPB) looks at the total cost of an inpatient stay and assigns the admission to the provider that charges the highest amount to Medicare under Part B billing. The costs for the episode of care include those incurred while an inpatient and also the cost for all outpatient services incurred three days prior to admission and 30 days following discharge.

How can radiologists have any hospital admissions?

Surprisingly, radiologists can be charged with hospital admissions under the MSPB methodology. A hospital admission is assigned to the provider that bills the highest dollar amount during the patient's episode of care. It's easy to see that diagnostic imaging could be a big part of preadmission services, whether the patient is an outpatient or in the emergency department. During the stay, such services as interventional radiology and radiation oncology will contribute greatly to the patient's total cost of care.

The best way to understand your practice's exposure is to review the 2016 Quality and Resource Use Reports (QRURs) available from CMS. Table 5B in the QRUR reports lists all patients attributed to the practice.

How do we report cost?

There is no separate reporting required, as CMS will gather the data taken from the Medicare claims submitted routinely by the practice. When sufficient data exist, there will be a bonus of 1 percentage point available for improvement year over year. Even though cost was not a factor until now, CMS has the data to calculate improvement and will apply it when warranted.

How do the cost measures become MIPS scores?

The TPCC score is calculated by CMS by totaling all of the annual Part A and Part B costs for the beneficiaries assigned to the practice and dividing that cost by the total number of assigned beneficiaries. A practice needs 20 episodes for the TPCC to count toward the MIPS cost category score, and it's unlikely that many radiologists will accumulate that number of TPCC episodes.

The MSPB score is calculated by CMS by totaling all of the costs for attributed patients and dividing that cost by the number of episodes of care. The resulting score will be measured against a peer group and scored accordingly. A practice needs 35 episodes of care for the MSPB measure to count toward the MIPS cost category score.

Radiologists who qualify for the MSPB score but not the TPCC will have the MSPB score as their total cost category score. In the event the practice does not qualify for either, then the cost category's 10% weight will be reassigned to the quality category.

How do we prepare?

Use the QRUR to understand your practice's historical data. From the data, you might be able to recognize a pattern of high costs and see how your cost scores compare with the national average. Try to understand why these patients are being attributed to your National Provider Identifier (NPI) or tax ID number under the two attribution methodologies.

The QRUR can be used to risk-stratify attributed beneficiaries' hierarchical condition category (HCC) percentile rankings cross-checked with 30-day readmission rates to identify potential cost-saving initiatives, such as transitional care management.


The 2018 measurement year is the first one in which the cost category is in effect, and it carries a weight of 10% toward the final MIPS score. In 2019, the category is scheduled to increase to a much more significant 30% of the final score. Now that radiologists understand how they might be participating in this category, it becomes important to learn how to manage your practice's score.

Richard Morris is the director of value-based strategy for Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of

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