American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Cost Performance Category

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The Cost component is worth 20 percent of the Merit-based Incentive Payment System (MIPS) final score in 2021, a 5 percentage point increase from 2020. The Centers for Medicare and Medicaid Services (CMS) will automatically calculate cost measures for the 2021 performance period based on claims data, meaning that THERE ARE NO REPORTING REQUIREMENTS FOR COST.

The MIPS cost category includes multiple cost measures. CMS will only hold a clinician or group accountable for a measure if the clinician or group is attributed a sufficient number of beneficiaries under each measure. Cost measures that will be used in 2021 include The Total Per Capita Cost (TPCC) for all attributed Medicare Beneficiaries measure, the Medicare Spending per Beneficiary (MSPB) measure, and multiple episode-specific cost measures. CMS did not add any new episode-based cost measures in 2021. The episode-based cost measures relevant to surgeons for 2021 are listed below:

  • Knee arthroplasty
  • Revascularization for lower extremity chronic critical limb ischemia
  • Routine cataract removal with intraocular lens implantation
  • Screening/surveillance colonoscopy
  • Elective primary hip arthroplasty
  • Femoral or inguinal hernia repair
  • Hemodialysis access creation
  • Lower gastrointestinal hemorrhage (applies to groups only)
  • Lumbar spine fusion for degenerative disease, 1-3 Levels
  • Lumpectomy partial mastectomy, simple mastectomy
  • Non-emergent coronary artery bypass graft
  • Renal or ureteral stone surgical treatment

It is more likely that surgeons could be attributed to the MSPB measure than the TPCC measure based on the attribution methodologies. The MSPB measure assesses Medicare Part A and B costs related to the care provided to a beneficiary during an episode defined as 3 days prior to a hospital admission (known as the "index admission") through 30 days after hospital discharge. A "surgical episode" is attributed to the surgeon(s) who performed any related surgical procedure during the inpatient stay (i.e., identified through surgical MS-DRGs), as well as to the TIN under which the surgeon(s) billed for the procedure. A surgeon (or TIN) must be attributed at least 35 patients under this measure to be scored on it.
For the episode-based cost measures, CMS will continue to use the following attribution methodologies:

  • For acute inpatient medical condition episode-based measures: An episode is attributed to each MIPS eligible clinician who bills inpatient E/M claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30 percent of the inpatient E/M claim lines in that hospitalization. A clinician or group must be attributed a minimum of 20 episodes to be scored on this type of measure.
  • For procedural episode-based measures: Episode is attributed to each MIPS eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes. A clinician or group must be attributed a minimum of 10 episodes to be scored on this type of measure.

Starting in 2021, MIPS eligible clinicians in MIPS APMs who report to traditional MIPS as individuals, groups, or virtual groups will be scored on cost. However, eligible clinicians in a MIPS APM that reports to traditional MIPS as a MIPS APM Entity will not be scored on cost. Instead, the cost performance category will be reweighted to 0% under traditional MIPS if the APM Entity reports quality and improvement activity data. The cost category will also be reweighted for clinicians who report via the new APM Performance Pathway (APP), either as an individual, group or MIPS APM Entity. More information about the APP is available here

CMS intends to provide feedback on 2020 cost measure performance data by the summer of 2021, in order for physicians to better understand their cost score. As the cost category weight and overall MIPS performance threshold continue to increase, it becomes increasingly important to understand your previous performance in this category. We recommend becoming familiar with your 2019 and 2020 feedback reports, as they will be good tools to assist in estimating possible scores for cost in 2021 and beyond. You can access performance feedback reports through the QPP website by signing in with your credentials (the same credentials used to submit and review data during the submission period).

If you meet the criteria for a facility-based clinician or group, CMS will use your Hospital Value-Based Purchasing (VBP) Program score in lieu of a MIPS score if the VBP score is higher than the clinician's combined Quality and Cost score under MIPS. Learn more about facility-based scoring.

Additional information about the cost category, including a Quick Start Guide and more detailed specifications for each measure, are available through the QPP Resource Library. CMS also offers a Cost Category fact sheet, which provides more details about the methodology for attributing and scoring these measures.