MIPS 101 for Anesthesia Providers

***Updated January 2020***

Are you an anesthesia provider participating in the Merit-Based Incentive Payment System (MIPS)? Let us tell you how the SurveyVitals solution might help you fulfill certain reporting requirements.

What is MIPS?

The Merit Incentive Payment System (MIPS) is one of two tracks in the QPP, the quality payment incentive program implemented by CMS. A small percentage of clinicians will qualify to participate in the Alternative Payment Models (APM) track, but most anesthesiologists will fall under the MIPS track.

You will receive a performance-based adjustment to your Medicare fee schedule in 2022 based on your MIPS performance in 2020. The amount of the adjustment, either positive, negative, or neutral, is based on an eligible clinician or group’s Composite Performance Score (CPS). The CPS is calculated using data across four categories of measurement.

Who participates?

If you bill Medicare Part B more than $90,000 in allowed charges per year and provide over 200 covered professional services under the Physician Fee Schedule for more than 200 unique Medicare patients a year, then you are part of the QPP. If you do not meet all three criteria, you could be exempt from participating in the program in 2020 under the the low-volume threshold exemption. Clinicians who meet the low-volume threshold may still opt in to MIPS if they meet at least one criterion.

To determine if you are required to participate in MIPS, CMS has provided a resource to check your status by entering your NPI into an eligibility “calculator.”

How are measures reported?

Anesthesiologists have the option to report as an individual, within a group, or within a virtual group.

Individual	Single NPI tied to a single Tax Identification Number (TIN)
Group	Single TIN with two or more eligible clinicians, including at least one MIPS-eligible clinician, as identified by their National Provider Identifiers (NPIs), who have reassigned their Medicare billing rights to the TIN
Virtual Group	Combination of two or more TINs assigned to one or more solo practitioners or one or more groups consisting of ten or fewer eligible clinicians

Reporting mechanisms vary based on reporting type and measure category. You can find more information on reporting mechanisms here.

How are measures selected?

Anesthesia providers and groups can select measures from the list of CMS-approved MIPS measures at the QPP website. Alternatively, they may select to report on Quality performance using specialized measures developed by a Qualified Clinical Data Registry (QCDR) of their choosing. QCDR measures must be approved each year by CMS.

Quality Category

Anesthesiologists are required to report on six measures of their choosing for the quality category. One of those measures must be an outcome measure.

SurveyVitals is equipped to help anesthesia clients utilizing a QCDR to meet an outcome measure (AQI 48 – Patient-Reported Experience with Anesthesia) in the Quality category. You must sign a disclaimer in order to report your patient experience data to a QCDR. View the reporting checklist, quick facts, and important deadlines here.

Improvement Activities (IA) Category

Anesthesia providers are required to participate in a combination of IA measures totaling 40 points. “High-weighted” activities are worth 20 points, while “medium-weighted” activities are valued at ten points. Your SurveyVitals solution can help you satisfy measures in the IA category. Download our “Road-Map to Improvement Activities” or contact us at info@surveyvitals.com to learn more.

In order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

Reporting requirements for Improvement Activities are reduced for non-patient facing clinicians, which are defined as either:

• An individual clinician that bills 100 or fewer patient-facing encounters (including Medicare telehealth services), or
• A group that provided more than 75 percent of the clinician’s billing under the group’s TIN

Those considered non-patient facing must participate in one high-weighted activity or two medium-weighted activities to satisfy the Improvement Activities category (for a total of 20 points rather than 40).

Always remember to check the eligibility calculator on the QPP website to confirm you are considered non-patient facing.

Promoting Interoperability Category

The Promoting Interoperability category places an emphasis on interoperability and patient engagement with certified EHR technology. Eligible clinicians must report on certain measures from four ‘objectives,’ or claims exclusions if applicable. Scoring is performance-based at the individual measure level, for a total of up to 100 points. In 2020, organizations must use the 2015 Edition CEHRT.

Cost Category

The score for the Cost category is calculated using administrative claims data. No data submission is required.

How can SurveyVitals help you succeed with MIPS?

SurveyVitals can help you meet one Quality measure and fulfill the entire Improvement Activities category. Reference the table below to see which measures we can help you meet.

MIPS Category	Measures We Support	More Information
Quality	AQI 48 (Outcome)	Anesthesia QCDR Reporting
Improvement Activities	High-weighted: IA_BE_6 IA_PSPA_11 Medium-weighted: IA_BE_13 IA_PSPA_4 IA_PSPA_18 IA_PSPA_19 IA_PSPA_20	Improvement Activities Roadmap

Want to learn how SurveyVitals can help you prepare for MIPS? Email us at support@surveyvitals.com. You can also send us a message using the blue chat icon below to speak to a member of our support team.

*Note: Information and program details are based solely upon SurveyVitals’ experience with MACRA and our interpretation of CMS rule-making and policy statements. The information presented does not reflect the views or policies of CMS or any other governmental agency and is not to be construed as practice management advice.

blake June 3rd, 2018 Categories: Anesthesia, MIPS Information

Tags: anesthesia, anesthesiologist, CRNA, improvement activities, macra, MIPS, QPP, quality category, quality payment program