MIPS: How CMS Attributes Patients to You for Quality and Resource Use Measures
MIPS, the CMS Merit-based Incentive Payment System, will determine the Medicare fee adjustments for payments made to physicians in 2019 using measurements from 2017. Diagnosis and service codes from the medical billing from all providers under Medicare Parts A and B are used to identify the patients qualifying for the various Quality and Resource Use Measures. Since Medicare patients often see multiple physicians (often the same patient sees many physicians for the same condition), the process to attribute patients to one or more of their physicians correctly can be complicated. These calculations depend exclusively on what is in the billing data from all providers. Without complete diagnosis and procedure coding by all physicians seeing a patient, attribution to a physician—and responsibility for the patient and measure—may be inappropriately assigned.
Attribution in Resource Use Measures
For the “Medicare Spending Per Beneficiary Measure” (MSPB) patients are attributed to the physician with what CMS calls the “plurality” of Medicare Part B charges for the period of three days prior to a hospital admission through 30 days after hospital discharge for the specific requirements of the hospital-based episodes (MS-DRGs) being evaluated. The same patient can be in several MSPB measure episodes during the measure year, with possibly different physicians attributed to each episode.
>>>>>>>How much of the mostly hospital services used were under the direction of any one physician will at some point need to be substantiated by CMS.
The “Total Per Capita Cost Measure” (including all Part A and Part B costs) for all beneficiaries uses a two-step CMS process to attribute patients to a physician. Medicare classifies and publishes the CMS list of mostly evaluation and management procedure codes, which it calls Primary Care Services. These are procedure codes for services commonly billed to CMS by most medical specialties. CMS considers physicians in any specialty that have provided the Primary Care Services. to be eligible for patient – physician attribution.
The two step attribution includes:
Step 1: Evaluate physicians in primary care specialties by taxpayer ID and National Provider Identifier (NPI) accounting for the larger share or “plurality” of the Primary Care Services – allowed charges compared to any other primary care physician. Attribute a beneficiary to one physician with the most allowed charges, or if a tie, with the most recent service in the evaluation year.
Step 2: If no primary care specialties have provided any Medicare Primary Care Services to the beneficiary, do the same attribution evaluation for physicians in any specialty.
>>>>>>>>Unfortunately for the attributed physician, no single physician can reasonably be responsible in Medicare fee-for-service for the totality of Medicare Per Capita Costs for any patient, since under the 1960-era Congressional authorization, beneficiaries can and do seek care without hesitation directly from almost any physician in any specialty, without a referral or coordination of care.
The “Episode Grouper for Medicare” measures will utilize relationship categories that CMS is developing. The current proposal from CMS has three proposed categories — “Continuing Care Relationship” for physicians that are (or should be responsible) for overseeing the ongoing care and coordination of care for the patient; “Acute Care” for physicians that are responsible for care for an acute episode/phase; and a third category for physicians who provide care but are not patient-facing, seeing the patient only through a referral from another physician. CMS attribution will accommodate multiple physicians to have the same patient and Episode of Care attributed to them. CMS’s proposed rule has any physician or physician group responsible for 30% or more of the evaluation and management services relevant to that Episode Group to have that patient attributed to them.
Attribution in Quality Measures
Each quality measure’s denominator criteria includes the applicable procedure and/or diagnosis codes that qualifies a patient for the measure. While the physician that coded the qualifying codes may have that patient attributed to him or her by default, the measures also include the statement: “This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure specific denominator coding.“ This stipulation allows for filtering based on the type of practice of the physician. PQRS measures under MACRA/MIPS will continue to be reported by the physicians to CMS using one of the submission methods that has also been in place prior to MACRA/MIPS.
There are additional quality measures that are calculated by CMS and will be included in the physicians’ MIPS Quality Domain score. Examples are the hospital utilization measures for ambulatory sensitive conditions (e.g., COPD and Pneumonia) and the All-Cause Hospital Readmission rate. CMS draft rules for these claims-based Quality Measures will use the same two-step process described above for the Total Per Capita Cost Measure.