MIPS reporting and payment adjustments for radiology

2018 03 16 20 44 0625 Morris Richard 20180316203124

The year 2019 marks the third reporting period under the Merit-Based Incentive Payment System (MIPS). The performance of radiology groups this year will determine their positive or negative Medicare fee schedule adjustment for payments in 2021, just as this year's Medicare payment adjustment was determined by performance in 2017.

Quality performance measures

Richard Morris.Richard Morris.

The MIPS program is revised annually by the U.S. Centers for Medicare and Medicaid Services (CMS), and practices have to be aware of the changes so they can optimize their performance. One of the annual adjustments is to move the bar a bit higher for physicians to meet quality objectives. When a quality measure's performance reaches a median of 95% or higher, it is designated as being "topped out" -- and after three consecutive years of being topped out, it is dropped from the list of available measures. For 2019, the measures listed below were eliminated.

For diagnostic radiology:

  • No. 359: Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging
  • No. 363: Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive

For radiation oncology:

  • No. 99: Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
  • No. 100: Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
  • No. 156: Oncology: Radiation Dose Limits to Normal Tissues

No measures related to interventional radiology were removed for 2019.

The task for radiology practices is to find replacements for these removed measures that will allow them to reach the minimum of six measures required for full reporting under the MIPS quality performance category. Healthcare Administrative Partners (HAP) has found that the measures below are generally attainable by diagnostic radiology practices.

Measures for diagnostic radiology practices
Measure ID Measure name National Quality Strategy (NQS) domain Measure type
145 Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy Patient Safety Process
146 Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms Efficiency and Cost Reduction Process
225 Radiology: Reminder System for Screening Mammograms Communication and Care Coordination Structure
361 Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry Patient Safety Structure
405 Appropriate Follow-Up Imaging for Incidental Abdominal Lesions Effective Clinical Care Process
406 Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients Effective Clinical Care Process
436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques Effective Clinical Care Process

All of these (except No. 436) are high-priority measures, the submission of which will earn bonus points for the practice.

Understanding payment adjustments

Practices that received the highest possible MIPS final score in 2017 earned a 1.88% positive adjustment to the Medicare fee schedule for payments in 2019. Does this mean you will see at least 1.88% more Medicare revenue than you did in 2018? The answer is different for each and every practice, but overall it is "probably not." Here's why.

There are many variables that go into the payment a practice receives for services to Medicare patients. For one thing, the fee schedule received an overall increase of 0.11% due to the conversion factor adjustment. Then, individual procedures were increased or decreased.

Finally, we have the adjustments for MIPS performance, either positive or negative, along with now-routine sequestration adjustment. The combination of all these factors will determine the final increase or decrease in total Medicare revenue for the practice.

With regard to the MIPS adjustment, however, we can illustrate how the reimbursement for a given procedure will be calculated. After determining the procedure's allowed amount from the Medicare fee schedule, and calculating the patient's deductible and coinsurance, the adjustments below will be applied.

Remittance Advice (RA) codes
Code Description Interpretation
CO-144 Incentive adjustment, e.g., preferred product or service Positive MIPS adjustment
CO-237 Legislated/regulatory penalty Negative MIPS adjustment
CO-253 Sequestration -- reduction in federal spending 2% mandatory reduction in Medicare payments

It's important to realize that these adjustments come after subtraction of the patient's deductible (if any) and the patient's 20% coinsurance amount from the fee schedule. The example in the table below uses a sample fee schedule amount of $1,000 and a 1.88% MIPS positive adjustment.

Reimbursement calculation example
Description Percentage Last year This year
Fee schedule amount   $1,000.00 $1,000.00
Applied to deductible (if any)   - -
Subtotal   $1,000.00 $1,000.00
Coinsurance 20% $(200.00) $(200.00)
Subtotal   $800.00 $800.00
MIPS incentive added 1.88%   $15.04
Subtotal   $800.00 $815.04
Sequestration deducted 2.00% $(16.00) $(16.30)
Net amount paid by Medicare   $784.00 $798.74
Increase this year     $14.74 or 1.88%

The practice does actually receive 1.88% more from Medicare this year than it would have for the same fee schedule amount last year. However, the MIPS adjustment and the sequestration reduction do not apply to the patient's responsibility for the deductible or coinsurance. Therefore, the total reimbursement for the procedure will be increased only 1.50% after all is said and done, as we see by continuing the example below.

Reimbursement calculation example (cont.)
  Last year This year
Net amount paid by Medicare $784.00 $798.74
Coinsurance paid by patient $200.00 $200.00
Total received by the practice $984.00 $998.74
Increase this year   $14.74 or 1.50%


It's important to keep on top of the annual changes to the Medicare Quality Payment Program (QPP), of which MIPS is one part. The reward for optimizing your practice's participation and the penalty for not participating will vary over time, becoming larger in both directions. Once you have done everything possible to maximize your score, it then becomes necessary to understand what that means in terms of actual payment two years later.

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 AuntMinnie.com.

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