Year three of the Quality Payment Program is here! There are some significant changes to be aware of as you plan what to do in 2019 to earn a bonus and avoid a penalty. Most eye-care providers will be in the Merit-Based Incentive Program, or MIPS. The program’s complexity for year three scoring is much higher since the scoring bar for penalty avoidance was raised to 30 points, which was doubled from the 2018 level. Year one of MIPS had a penalty avoidance of only three points.

What are the four main parts of MIPS and how has the weight of each changed for year three?

A: The weight of each year-three MIPS component (adding up to 100 percent) is as follows:

• Quality = 45 percent

• Resource Use (Cost) = 15 percent

• Improvement Activities (IA) = 15 percent

• Program Interoperability (PI) = 25 percent.

Program Interoperability might seem like a new MIPS category, but it was renamed mid-2018 by CMS. It was formerly known as Advancing Care Information, but it’s still the electronic medical record portion of MIPS. If you don’t have an electronic medical record system in your practice and have no exemption, your maximum score is limited to 75 points since you can’t score in Program Interoperability. 

Two of the categories, Quality and Resource Use, have had their emphases/weighting changed every year since the program’s inception in 2017. In the second year, Quality was worth 50 percent, while the Resource Use category was worth 10 percent.

In some instances, when a provider or group receives an exemption or no score from the Program Interoperability, Improvement Activities or Cost categories, the weight of the category with the exemption or no score is added to the weight of the Quality category. For example, if a practice had a hardship exception for Program Interoperability, then the associated 25 percent would be added to Quality’s 45 percent value, making the new weight 70 percent.

Q: What hasn’t changed for 2019 MIPS?

A: If you’re considered a small practice (fewer than 16 providers) then CMS retains the IA score-doubling effect. To get 100 percent, you only need to reach half the maximum score of 40. Large practices of 16 or more providers still have to reach 40 points the normal way. Other 2019 MIPS provisions that haven’t changed include the ability to choose to report as an individual, group or virtual group. Additionally, data for Quality and Resource Use is still collected for the entire year, while data for PI and IA is still collected for any 90 or more consecutive days. 

As in past years, what you do this year has the potential to affect your Medicare payments two years later; so, the 2019 MIPS component
affects 2021 payments. CMS refers to these as the “Performance Year” and “Payment Year.”

I reported MIPS via a registry in 2017 and 2018. Have the submission methods changed?

A: No. You can still submit via Claims if you’re a small group, and the Direct EMR and Registry options remain for anyone. If you submit the same MIPS category using multiple methods (for example, if you report Quality via both Claims and Registry), your highest score will count.

For 2018, I’m receiving a small-practice bonus of five points, which will be added to my MIPS Composite score. Is this bonus still available in 2019?

A: The bonus is now six points, but instead of applying that to the Composite score, it all goes to Quality, which has the effect of diluting the bonus points.

Did any of the areas undergo changes I should know about that aren’t noted above?

A: Yes. Both PI and Resource Use changed in significant ways. The 2018 method of reporting PI involved having a “Base” that you had to meet before going to a “Performance” score. That was changed; there’s just one level now. In 2018, there were more than 150 possible PI points, and you only had to reach 100 to max out that category and get 100 percent. For 2019, there are only 100 possible points. There are some bonus points in PI, which can total 10 points, but they are unlikely to be achieved by ophthalmologists, who won’t have prescription drug monitoring programs and opioid treatment agreements. As a result of these changes, getting a perfect score of 100 percent may be more difficult.

For Resource Use, if your office does cataract surgery in an ASC or HOPD, this is the biggest change of all. There’s a new “Episode of Cost” measure which takes into account uncomplicated cataract with intraocular lens surgery and all of the associated costs. At the end of the year, CMS will calculate a normalized value for 66984, which takes into account regional differences, site of surgery and other factors. That value is then multiplied by the number of cases, if you reach the case minimum. 

Here are a few important specifics that you should know regarding this change:

• Only items/amounts paid by Medicare for uncomplicated CPT 66984 are counted. Claims to other payers are not part of this; neither are patient-pay, noncovered services such as premium IOLs.

• You need to have been paid for 20 or more 66984 claims to Medicare for 2019 surgery that are not otherwise excluded (see below).

• Anything paid by Medicare related to cataract within a window of 60 to 90 days before the surgery can count.

• All costs paid by Medicare related to the cataract surgery count, which includes all of the related exams, diagnostic tests, reoperations (for example early YAG capsulotomy or IOL repositions, even if not done by the initial surgeon), any drugs used during the surgery or in the office that are separately paid, and anesthesia payments.

• Patients who have concomitant ocular disease which might limit best-corrected visual acuity aren’t counted (such as situations where the patient has a corneal scar or significant posterior segment disease). The Centers for Medicare and Medicaid Services dictates the exclusions by looking at diagnosis codes for the eye that’s having surgery as well as the “time window” above.

The two-step attribution process for “primary-care services,” which was always unlikely to apply to eye doctors, still remains.

If any costs are attributed to a surgeon—or the surgeon’s group, if reporting that way—using either or both of the methods described above, then you are compared to the national norm for cost and scored accordingly. Those who are low-cost would be given a higher Resource Use score. If both two-step and cataract are attributed, each scores in this category. If only one of these applies, then that counts in full for the category. Here, a perfect score would be 10 points on each part scored, which is multiplied by the 2019 weight of 15 percent.

I’ve heard that some medical practices could receive an exemption for some or all of MIPS. Is that true?

A: Yes, if a large natural disaster affects the practice. This was true in both 2017 and 2018 and is likely for 2019, too. However, as we are barely into the year, CMS has not issued any information for 2019 disasters at the time of this writing, since none have occurred.

Those practices who are affected by wildfires or other natural disasters (CMS calls these “extreme and uncontrollable circumstances”) are likely to be given a “pass” on part or all of 2019 MIPS reporting and will therefore receive no penalty in 2021 unless they are able to and elect to submit MIPS data. CMS automatically identifies these areas by their payment ZIP codes. There are other exemptions published by CMS but they are far less likely to apply to the average practice.

Ultimately, what it comes down to is that 2019 MIPS is more complicated this year, and diligence is warranted in order for your practice to avoid a 2021 penalty.  REVIEW


Mr. Larson is a senior consultant at the Corcoran Consulting Group in San Bernardino, California. He can be contacted at