Changes in the Merit-based Incentive Payment Systems (MIPS) from 2017 to 2018 include:

• CMS considers 2018 a transition year.  So, while it is not as easy to avoid the penalty in 2018 as it was in 2017, there are ways to do so without full participation in MIPS.
• Eligible clinicians (ECs) are to participate in all four components of MIPS, but the categories are not weighted equally toward the composite score.
  • Quality - 50 percent
  • Advancing Care Information (ACI) - 25 percent
  • Improvement Activities - 15 percent
  • Cost - 10 percent
• If an EC does not participate in MIPS, he/she will incur a -5 percent payment adjustment (penalty) on his/her Medicare Part B payments in 2020.  This is up from -4 percent in 2017.
• An EC is excluded from MIPS if he/she sees 200 or fewer Medicare Part B patients or has $90,000 or less in Part B allowed charges
• Multiple opportunities are available to earn bonus points. See reporting categories for details.
• There are resources and other perks available for small (15 or fewer clinicians) and/or rural practices. 
  • 5 bonus points toward final score for small practices
  • Even if a small practice does not meet the data completeness requirement for Quality, 3 points will be awarded
  • Only required to complete two Improvement Activities
• The performance threshold is now 15 (versus 3 in 2017). In 2017, if an EC reported one measure for one patient, he/she would receive a performance score of 3 which allowed the provider to avoid the penalty. In 2018, an EC has to participate enough to earn 15 points to avoid the penalty. There are a variety of ways to achieve this.

Reporting as an Individual or a Group

Providers may report as individuals where they are independently scored on the data they submit to CMS. Alternatively, they may report as a group, which CMS defines as two or more eligible clinicians (as identified by individual National Provider Identifiers or NPIs) who have reassigned their billing rights to a single Taxpayer Identification Number (TIN). The group’s score is a composite of all the clinicians’ scores.

Reporting Options

There are several different reporting options which may be selected to participate in the Quality Reporting program.

Claims reporting is the most frequently used process for urologists. However, those who are reporting individually may only use it. It involves reporting extra CPT Category II codes (also known as Quality Data Codes or G codes) along with regular billing CPT codes and diagnosis codes on electronic or paper claims submitted to Medicare. Medicare then forwards these claims files to the processor. Participants must report at least 50 percent of only the Medicare Part B patients to which a measure applies.

Qualified Registry reporting may be used by both individuals and groups. It is accomplished by contracting with a CMS-approved data processing service that can compile patient claims data and generate reports on a provider or practice's behalf directly to the MIPS processor. Those using a Qualified Registry must report at least 50 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient). CMS annually publishes a list of approved Qualified Registries.

A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity (such as a registry, certification board, specialty society, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. Individuals and groups may report via a QCDR. Those using a QCDR must report at least 50 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient). CMS annually publishes a list of approved QCDRs. The AUA offers its own QCDR, the AQUA Registry. For more information, contact 855-898-AQUA (2782) or AQUA@AUAnet.org.

Electronic Health Record (EHR) reporting involves either submitting one’s data directly to CMS or to a vendor who will then submit it to CMS on the provider or practice’s behalf. Check with your EHR vendor to find out what option(s) is available to you. Both individuals and groups may use EHR reporting, and this method may allow you to qualify for bonus points in Advancing Care Information. Those using EHR reporting must submit data for at least 50 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient).

Web Interface reporting is available for groups of 25 or more clinicians who register with CMS before the June 2018 deadline. Users must report on all 15 Web Interface measures for the entire calendar year of 2018 for the first 248 eligible assigned MIPS beneficiaries. If a group does not have 248 such beneficiaries, the group must report on 100 percent of their assigned beneficiaries. For more information, see the CMS Web measures list.

There are over 300 individual measures to consider for Quality reporting in 2018. In order to help urologists find specialty specific measures, CMS created a Urology Measures Set. If you select 6 measures from this list, you do not need to report an outcome measure. However, you must select at least 1 high priority measure from the list. The AUA has also compiled a list of measures which are most applicable for urologists. If you select six measures from this list, you must report at least one outcome measure.

Previously the AUA recommended that participants consider the clinical conditions they treat, any practice improvement goals, work currently being done in the practice and quality information that may be already be reported to other payers or entities when selecting measures. While that remains good advice, one also needs to look at possible scoring too. Under PQRS, success was measured on a pass/fail basis. One either reported and passed or did not report (or did so incorrectly) and failed. Now it is more complicated. CMS gauges how well a participant scores on a measure and assigns them a point total. The points for the top six reported measures are added to comprise one's Quality score.  Some measures only allow limited scoring. (See the Benchmarking section below for more details.) Therefore, participants also need to assess how well they can score on the measures they select.  

Measure Specifications and Flowcharts [pdf]

• Measure #23 – Perioperative Care, Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) [Claims, Registry]
• Measure #46 – Medication Reconciliation [Claims, Registry]
• Measure #47 – Advance Care Plan [Registry]
• Measure #48 – Urinary Incontinence, Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [Claims, Registry]
• Measure #50 – Urinary Incontinence, Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older [Claims, Registry]
• Measure #102 – Prostate Cancer, Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients [Registry, EHR]
• Measure #104 – Prostate Cancer, Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients [Registry]
• Measure #110 – Preventive Care and Screening, Influenza Immunization [Claims, Registry, EHR]
• Measure #113 – Colorectal Cancer Screening [Claims, Registry, EHR]
• Measure #119 – Diabetes, Medical Attention for Nephropathy [Registry, EHR]
• Measure #122 – Adult Kidney Disease: Blood Pressure Management [Registry]
• Measure #128 – Preventive Care and Screening, Body Mass Index (BMI) Screening and Follow-Up [Claims, Registry, EHR]
• Measure #130 – Documentation of Current Medications in the Medical Record [Claims, Registry, EHR]
• Measure #131 – Pain Assessment and Follow-Up [Claims, Registry]
• Measure #143 – Oncology: Medical and Radiation – Pain Intensity Quantified [Registry, EHR]
• Measure #144 – Oncology: Medical and Radiation – Plan of Care for Pain [Registry]
• Measure #145 – Radiology: Exposure Time Reported for Procedures Using Fluoroscopy [Claims, Registry]
• Measure #226 – Preventive Care and Screening, Tobacco Use, Screening and Cessation Intervention [Claims, Registry, EHR]
• Measure #236 – Controlling High Blood Pressure [Claims, Registry, EHR]
• Measure #238 – Use of High-Risk Medications in the Elderly [Registry, EHR]
• Measure #265 – Biopsy Follow-Up [Registry]
• Measure #317 – Preventive Care and Screening, Screening for High Blood Pressure and Follow-Up Documented [Claims, Registry, EHR]
• Measure #321 – CAHPS for PQRS Clinician/Group Survey
• Measure #357 – Surgical Site Infection (SSI) [Registry]
• Measure #358 – Patient-centered Surgical Risk Assessment and Communication [Registry]
• Measure #408 – Opioid Therapy Follow-up Evaluation [Registry]
• Measure #412 – Documentation of Signed Opioid Treatment Agreement [Registry]
• Measure #414 – Evaluation or Interview for Risk of Opioid Misuse [Registry]
• Measure #422 – Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury [Claims, Registry]
• Measure #428 – Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence [Registry]
• Measure #429 – Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy [Claims, Registry]
• Measure #431 – Preventive Care and Screening, Unhealthy Alcohol Use: Screening & Brief Counseling [Registry]
• Measure #432 – Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
• Measure #433 – Proportion of Patients Sustaining a Major Viscus Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
• Measure #434 – Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
• Measure #436 – Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques [Claims, Registry]
• Measure #453 – Proportion Receiving Chemotherapy for the Last 14 Days of Life [Registry]
• Measure #454 – Proportion of Patients Who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life [Registry]
• Measure #455 – Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life [Registry]

Under the Quality Reporting program, participants are scored on how complete and successful their reporting is in comparison to others who are reporting. For each measure and for each reporting mechanism, a series of benchmarks have been established. CMS has created a matrix where each measure has been divided into deciles, ranging from 3 to 10. A participant will be able to use this matrix to determine into which decile his/her work falls and thus determine his/her score for that particular measure. For example, let's say a urologist is reporting Measure #130 Documentation of Current Medications in the Medical Record using claims reporting. The range for this measure is:

To achieve 10 points for this measure, a participant must have a perfect score, meaning he/she correctly reported on all the patients to which this measure was applicable. If he/she missed a couple of patients, his/her score would obviously decrease. For this particular measure, the participant’s score would drop down to 5 points at the maximum for anything less than perfection, but a score could be much lower because the score would need to be very close to perfection in order to get more than 3 points.

The scoring on Measure #130 is very tough because it is considered a “topped out” measure by CMS. This means that it has been widely used, and users score very well on it. CMS will begin to phase out many of the topped out measures in the coming years. CMS is trying to discourage participants from using these measures by awarding lower point values. In contrast, Measure #113 Colorectal Cancer Screening is not topped out; therefore, the ranges are wider:

Measure #113 Colorectal Cancer Screening, Claims Reporting

A participant cannot score less than 3 points in 2018 for any measure reported, but CMS may not continue this in the future. Also, if a measure is new for 2018, CMS will initially award 3 points for that measure no matter how well the participant scores. The point value may change after the reporting year ends if CMS is able to collect enough data in order to calculate a benchmark; however, there is no guarantee that will happen.

Each measure, and its reporting mechanism, has its own unique benchmarks. So, participants will want to assess the potential benchmarks when they contemplate which measures to report. Also, reporting a measure through claims reporting will have a different benchmark than reporting it through a registry. Here is an example using Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older.

Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older, Claims Reporting

Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older, Registry/QCDR Reporting

The matrix of benchmark scores is located in the MIPS 2018 resources of CMS's website and is labeled Quality Benchmarks. The AUA has assembled a listing of the benchmarks for the measures on its recommended list.

A clinician's Quality reporting score will account for 50 percent of one's overall MIPS score.

To figure a provider's Quality reporting program score, one must determine the benchmark for each measure used. Those scores are added together and divided by 60. The score is displayed as a percentage, but a maximum score cannot exceed 100 percent. For example, if you scored perfectly on all 6 measures and achieved 10 points for each, you would have 60 divided by 60 for 100 percent. However, most people will fall below that. For example, someone's scores could be 3, 8, 7, 4, 5, and 9 = 36 points. This divided by 60 would give you 60 percent. In 2018, it is possible to earn bonus points. However, you may not earn more than 12 total Quality bonus points. The following are bonus points applied to measure scores:

• 2 bonus points for each additional outcome and patient experience measure
• 1 bonus point for each additional high-priority measure
• 1 bonus point per measure for using Certified Electronic Health Record Technology (CEHRT) to submit measures to a registry/QCDR or CMS (end-to-end electronic reporting)

The following are bonus points applied to the final score:

• Up to 5 bonus points toward final score for treatment of complex patients
• 5 bonus points toward final score for small practices

Also, if a practice has 16 or more eligible clinicians, CMS will calculate the All-Cause Hospital Readmission measure for the claims the practice submitted for the year. The calculation is added to the final MIPS score. Providers do not need to do any work for this calculation; it is all done by CMS.

How Do Improvement Activities Fit into MIPS?

The Merit-based Incentive Payment System (MIPS) is a four-part program. IAs account for 15 percent of one's total MIPS score.

How Are Improvement Activities Scored?

In this program, one must participate in enough activities for a minimum of 90 days to earn 40 points. All IAs are weighted either high (20 points) or medium (10 points). Participants can complete any arrangement of activities which earns 40 points. However, if a provider belongs to a practice with fewer than 15 providers or if a provider practices in a rural or health professional shortage area, then only 20 points are needed. Participants still need to complete the activities for a minimum of 90 days.

Do I report individually or as a group?

IAs can be reported by individuals or through group reporting. Some IAs (such as participation in the Consumer Assessment of Healthcare Providers and Systems Survey-Patient Safety and Practice Assessment #11) can only be done by groups. If you opt to use group reporting for one MIPS category, it must be used for the other MIPS categories. If a practice is using group reporting, all members of the practice earn credit for any IA completed by any member. For example, there may be five members in the practice and if one of them completes routine medication reconciliation for 90 days (Population Management #15), then all five members get credit for this activity.

How do I start?

The focus of Improvement Activities is improving the care provided to your patients, and CMS believes that focusing on specific activities for a designated time period can stimulate this care. It is important that you first do an analysis of your practice:

• What are areas that need improvement?
• What changes would patients most appreciate?
• Are you currently doing improvement activities which would qualify for this program?

Then brainstorm what you can do. Hopefully, if you do need to start new or amend existing activities, you can implement something small which will not require a significant outlay of time, staffing or other resources. For example, are there programs offered through your local hospital system or through an insurance program which could satisfy an Improvement Activities requirement?

What do I choose?

There are 111 IAs organized into eight categories:

• Integrated Behavioral and Mental Health (BMH)
• Expanded Practice Access (EPA)
• Population Management (PM)
• Care Coordination (CC)
• Beneficiary Engagement (BE)
• Patient Safety and Practice Assessment (PSPA)
• Achieving Health Equity (AHE)
• Emergency Response and Preparedness (ERP)

The AUA has reviewed the complete list of Improvement Activities and has identified several which most urologists should be able to easily implement or adapt for their practices. These activities are highlighted in blue. However, you should review the entire list to see if there are other IAs which may be more applicable to your practice. Some practices may find that an option not selected by the AUA would be a proper fit. Additionally, several activities are highlighted in green; these can be completed through use of the AUA's Qualified Clinical Data Registry (QCDR), the AQUA Registry. If you are not yet a member of the AQUA Registry and wish to consider this reporting option, contact AQUA@AUAnet.org or 855-898-AQUA (2782) for more information. Remember you must participate in whatever activities you choose for 90 consecutive days.

Key Tips

You do not need to report or submit information to CMS as part of Improvement Activities. Rather in early 2019, CMS will require you to attest to whatever action you completed in 2018. One can attest through the CMS Quality Payment Program website, QCDR, qualified registry, electronic health record system (verify your EHR has this capability), or CMS Web Interface (if there are 25 or more providers in the practice). Eligible clinicians and groups only need to attest via the Quality Payment Program website that they completed the improvement activities they selected or should work with their vendor to determine the best way to submit their activities via a qualified clinical data registry (QCDR), a qualified registry, or their electronic health record system.

Because there are many unknowns about this program, the AUA recommends that you document as much information as possible about the activities you complete. For example, if you are administering a patient satisfaction survey for 90 days, note in the patient charts who received one and when. If you attend an Institute for Healthcare Improvement event, save your registration and any materials (slides, handouts, etc.) which may have been distributed regarding the event. CMS always has the ability to audit your submissions; so, it is wise to have some kind of verification to prove what you have done. Eligible clinicians are encouraged to retain documentation for six years as required by the CMS document retention policy.

If you choose to participate in MIPS via a QCDR, you must select and achieve each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR.

Sometimes the work you will be doing will satisfy multiple Improvement Activities. You might want to consider taking advantage of this overlap.

Improvement Activity Resources

Several links and resources included in this Toolkit are available to provide more direction and guidance. It is important to note that each practice is unique, and in order to improve the care provided to patients, it is best to individualize what you will be doing as much as possible. The models and information here can serve as a basis for something that you will need to tweak slightly to make applicable to your practice.

While the AUA identified 38 activities as achievable for urologists, some will be easier than others. The following PDF provides details and resources available to help with these activities. Note: The Quality Reporting measures listed on AUAnet.org are for the Registry option. Claim options are also available.

• Additional Improvement Activity Resources Specific to Urologists

The Cost category is a new version of CMS' Value Modifier program. While CMS collected Cost data in 2017, it was not scored. However, in 2018, the program will be scored, and the program will count for 10 percent of one's overall score in 2018. The category shows:

• The resources clinicians use to provide patient care
• The Medicare's expenses per beneficiary during an episode of care.  In other words, what items and services for claims are utilized by a patient in a specified timeframe for certain procedures/care.

What do I have to do? How is the Cost category figured?

The good part about the Cost category is that you do not have to do a thing. CMS will use Medicare claims data to calculate your score. However, that may also work against you. The AUA found that in the Value Based Modifier, CMS attributed patients to urologists when they should not have done so. Occasionally urologists were being penalized for not providing care for chronic conditions that are outside the scope of urology.

What Cost measures will be used in 2018?

There will be two measures in 2018.

1) Total per Capita Cost (TPCC) - This measures all Medicare Part A and Part B costs during the year.

2)  Medicare Spending per Beneficiary (MSPB) - The MSPB clinician measure determines what Medicare pays for services performed by an individual clinician during an MSPB episode: the period immediately before, during, and after a patient's hospital stay.  An MSPB episode includes all Medicare Part A and Part B claims during the episode, specifically claims with a start date between three days before a hospital admission (the "index admission" for the episode) through 30 days after hospital discharge.

For more details about these two measures, check out the 2018 Cost Performance Category Fact Sheet.

How will I be scored?

If a provider/group has seen the minimum attributed beneficiaries (20 cases for total per capita cost measure or 35 cases for MSPB measure), CMS will calculate the Cost performance score.   If the case minimums are not met for either of the measures, CMS will reweight the Cost performance category weight to the Quality performance category.  This will make the Quality performance category worth 60 percent of one's 2018 MIPS total score.

To figure your Cost performance category score, CMS will assign a score of 1-10 points to each measure.  Secondly, they will compare your performance to other MIPS-eligible clinicians' and groups' during the performance period. 

                                                 Total Points Scored on Each Measure

 Cost Performance       =         Total Possible Points Available

The Cost performance category score is the average of the two measures, but if only one measure can be scored, that score will be the performance category score. 

Where can I get more information?

2018 Cost Performance Category Fact Sheet

"Know Before You Go" Information

Advancing Care Information (ACI) is the new iteration of Meaningful Use, and it accounts for 25 percent of the overall MIPS score in 2018. In April 2018, CMS announced that they have changed the name of Advancing Care Information to Promoting Interoperability. While the program's name has changed, all other facets of the program remain the same. The AUA has used the two program titles in this explanatory material interchangeably.

The goal of Promoting Interoperability is to increase the effective use of Certified Electronic Health Record Technology (CEHRT). Those without an EHR should still participate in MIPS. However, they will receive a 0 for the ACI category.

In order to report for ACI, participants can use one of the following methods: a qualified registry, qualified clinical data registry (QCDR), EHR, CMS Web Interface, or attestation.

Participants can report as an individual or a group. Whatever option is selected must be used for all MIPS categories.

Reporting for ACI must be done in a consecutive 90-day period at any point during the calendar year.

One should determine what version of CEHRT his/her EHR is. It will either be the 2014 or 2015. Those who have a 2015 version and report exclusively with it can earn a 10 percent bonus. If you are unsure what version of CEHRT you have, check with your EHR vendor.

Exclusions and exemptions are available. However, not having an EHR does not qualify you for either. For more information, contact the QPP help desk at 866-288-8292 or QPP@cms.hhs.gov.

What do I do?

There are two primary sets of measures [ACI/ACI Transition measures (also known as base measures) and performance measures] as well as bonus measures. The base measures show if a provider performed an activity and the performance measures assess how well the measure was performed. 

ACI Measures/ACI Transitions Measures - Participants must report all of the ACI/ACI Transition measures. If they do, they will receive 50 points, but if they do not report these measures, their ACI category score will be zero. In order to receive credit, participants must a "yes" for the security risk analysis measure, and at least a 1 in the numerator for the remaining measures. The measures are:

• Security Risk Analysis
•  e-Prescribing
• Provide Patient Access
• Send a Summary of Care*
• Request/Accept a Summary of Care*

* In 2018 Advancing Care Information, these measures are bundled together as Health Information Exchange.

Performance Measures - These measures are scored using the numerators and denominators submitted (and for the Immunization Registry Reporting measure, the yes or no answer submitted). Thus, each measure is scored individually and participants can earn up to 10 points per measure depending how well they do. Three of the base measures can also be included in the performance score. Additional measures can be reported in order to increase one's performance score. Participants can earn up to 90 performance percentage points toward their ACI category score. Most measures are worth a maximum of 10 percentage points with two exceptions in the 2018 Transition measures, which are worth 20 percentage points. 

* These measures are also ACI/ACI Transition (base) measures.

Points are assigned based on performance per measure according to the following scale:

Bonus Measures - Participants can earn bonus percentage points for the following: 

• Report yes to one or more additional public health and clinical data registries beyond the Immunization Registry Reporting measure. This will be 5 percent bonus.
• Report yes to the completion of at least one of the specified Improvement Activities using CEHRT.  This will be a 10 percent bonus.
• Report exclusively using the 2018 Advancing Care Information Objectives and Measures using 2015 edition CEHRT.  This will be a 10 percent bonus.

How is my score figured?

The ACI Information score is the sum of these 3 scores:

𝐴𝐶𝐼 𝐵𝑎𝑠𝑒 𝑆𝑐𝑜𝑟𝑒 (50 percent) + 𝐴𝐶𝐼 𝑃𝑒𝑟𝑓𝑜𝑟𝑚𝑎𝑛𝑐𝑒 𝑆𝑐𝑜𝑟𝑒 (up to 90 percent) + 𝐴𝐶𝐼 𝐵𝑜𝑛𝑢𝑠 𝑆𝑐𝑜𝑟𝑒 (up to 20 or 25 percent) = 𝑇𝑜𝑡𝑎𝑙 𝐴𝐶𝐼 𝑆𝑐𝑜𝑟𝑒

The Total ACI Score is capped at 100 percent. 

The Total ACI score is then multiplied by 25 percent (the category weight).

Where can I get more information?

2018 MIPS Advancing Care Information Performance Category Fact Sheet

Quality Payment Program: Advancing Care Information

Measure specifications are available at qpp.cms.gov

Quality Payment Program Help Desk
Phone: 866-288-8292
Email:QPP@cms.hhs.gov

AUA
Phone: 410-689-3925
Email: quality@auanet.org