Q: I saw Medicare has released the 2020 Proposed Rule. Can you tell me if there are changes for the QPP/MIPS program next year?

A: Yes—and they are significant, so planning is a key part of this. Let’s review what is needed this year (2019) before moving on to next year. Participation in QPP is still as either a group or an individual. Since few ophthalmologists are in advanced alternative payment models (APM), MIPS is likely their only option under QPP. If you’re not exempt from QPP this year, you’ll need a minimum of 30 points to avoid the penalty in 2021 for your 2019 “performance year” activities. The “Cost” category is likely to impact any ophthalmologist who performs routine cataract surgery with IOL placement. If you aren’t exempt and don’t participate as either a group or individual in MIPS, and aren’t part of an advanced APM, you would be penalized in 2021 the maximum 7 percent on all Part B services except office-administered Part B drugs.

What score do I need next year to avoid the maximum penalty in 2022?

A: This is the biggest change, in my opinion. The bar is raised to 45 points for 2020 reporting. Additionally, the maximum penalty is now 9 percent. The maximum bonus is up to 9 percent too, but it’s budget neutral, which has significantly affected what providers have been able to get each year. Even earning a 100-percent score hasn’t allowed providers to get what was theoretically possible. Those doing claims-based reporting may have to work hard to achieve 45 points, although reaching the mid-30s and getting a much lower penalty is likely doable (it’s why most doctors can avoid the maximum 7-percent penalty in 2019). Historically, those who report via a Registry have a much better chance to score higher than those doing claims-based reporting.


Q: Are the categories being re-weighted again in 2020?

A: Yes. “Cost” rises to 20 percent from the current level of 15 percent. “Quality” goes down to 40 percent from the current 45-percent level, continuing the downward trend. “Program Interoperability” (a.k.a., “PI,” the EMR one) stays at 25 percent and Improvement Activities stays at 15 percent. In fact, CMS notes that by the 2022 performance year, Cost and Quality are each anticipated to be weighted at 30 percent.


Q: What’s going to happen to the Cost category of MIPS in 2020?

 Another big change is possible in the category of Cost. Many of you may remember the big change this year was the implementation of the Episode of Cost for Routine Cataract with IOL. Those doing routine, uncomplicated cases coded as 66984 for patients without certain concomitant diagnoses (such as age-related macular degeneration) are now scored in the Cost category. This Cost episode is proposed to continue for 2020 without change, but there is a proposal to modify one of the two other ways to be scored in this category (TPCC, or Total Per Capita Cost). While, historically, this hasn’t affected many eye-care providers, it doesn’t mesh well with how eye doctors practice and the proposed change was seen as unfair to those affected. The last way to get scored here (MPSB, or Medicare Spending Per Beneficiary) remains, but might possibly change in a more subtle way.


Q: Has there been a proposal to change the EMR area of MIPS?

A: Again, the answer is yes. This area is now known as Program Interoperability (PI). When MIPS started, it was known as “Advancing Care Information.” Before that, we knew it as “Meaningful Use.” This latest change isn’t going to impact many ophthalmologists. CMS proposes to remove the “Verify Opioid Treatment Agreement” measure and make the “Query of Prescription Drug Monitoring Program” optional. CMS proposes to keep the small practice exceptions here.

How about Improvement Activities (IA)? Any changes there?

A: CMS proposes to survey doctors and groups about changes, but plans no changes other than to require half of the doctors in a group to participate for IA to count (instead of only one doctor, as the rule states now). If a provider is hospital-based, the threshold will be 75 percent of providers. 

The small practice doubling of IA scoring for those practices under 16 providers is slated to remain, as well, so you can still score 20 but yield 40 (the maximum) in 2020. CMS also proposes to begin developing a process for deciding how/when IA measures are removed.


Q: What changes are afoot for the Quality area of MIPS?

A: Other than the Quality scoring weight changing to 40 as mentioned, the reporting thresholds are increasing to 70 percent for both claims-based reporters and those using Registries or direct electronic health records reporting. For claims-based reporters, this is 70 percent of Part B patients, and for those with Registries or electronic health records systems it’s 70 percent of all patients. The Centers for Medicare and Medicaid Services proposes to remove measures 192 (Complications within 90 days of Cataract/IOL that require additional surgery) and 388 (Unplanned rupture of posterior capsule requiring unplanned vitrectomy). The process for removing Quality measures continues so it’s likely there may be fewer options for providers to choose from, or that scoring may become more difficult for those that remain in 2020.


Q: What other changes should ophthalmologists be aware of?

A: Cost and Quality reporting remains a full year, and PI and IA stay at 90 days (no change). Finally, we haven’t covered everything. You can see the proposed 2020 changes for QPP and MIPS on the QPP Resource Library page at this link: https://qpp.cms.gov/about/resource-library. The downloadable document(s) that ophthalmologists will need for the 2020 billing year are near the top of the page right under the menu marked “Regulatory Resources.”

CMS also proposed a new “MIPS Value Pathways” (MVP) system for 2021 but that won’t change your 2020 reporting.  REVIEW


Mr. Larson is a senior consultant at the Corcoran Consulting Group. Contact him at plarson@corcoranccg.com.