American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Cost Performance Category

Cost 15%

The Cost component is worth 15 percent of the Merit-based Incentive Payment System (MIPS) final score in 2020, remaining the same from 2019. The Centers for Medicare and Medicaid Services (CMS) will calculate cost for the 2020 performance period using data from claims , meaning that surgeons will not need to take any action with respect to reporting for cost. THERE ARE NO REPORTING REQUIREMENTS FOR COST.

The MIPS cost category includes multiple cost measures. CMS will only hold a clinician or group accountable for a measure if the clinician or group is attributed a sufficient number of beneficiaries under each measure. Cost measures that will be used in 2020 include The Total Per Capita Cost (TPCC) for all attributed Medicare Beneficiaries measure, the Medicare Spending per Beneficiary (MSPB) measure, and multiple more focused episode-based cost measures. In 2020, the episode-based cost measures relevant to surgeons are listed below:

  • Knee arthroplasty
  • Revascularization for lower extremity chronic critical limb ischemia
  • Routine cataract removal with intraocular lens implantation
  • Screening/surveillance colonoscopy
  • Elective primary hip arthroplasty
  • Femoral or inguinal hernia repair
  • Hemodialysis access creation
  • Lower gastrointestinal hemorrhage (applies to groups only)
  • Lumbar spine fusion for degenerative disease, 1-3 Levels
  • Lumpectomy partial mastectomy, simple mastectomy
  • Non-emergent coronary artery bypass graft 
  • Renal or ureteral stone surgical treatment

CMS recently made revisions to the TPCC measure attribution methodology that limit its applicability to surgeons. However, surgeons may be attributed surgical episodes under the newly revised MSPB measure, which assess Medicare Part A and B costs related to the care provided to a beneficiary during an episode defined as 3 days prior to a hospital admission (known as the "index admission") through 30 days after hospital discharge. A "surgical episode" is attributed to the surgeon(s) who performed any related surgical procedure during the inpatient stay (i.e., identified through surgical MS-DRGs), as well as to the TIN under which the surgeon(s) billed for the procedure. A surgeon (or TIN) must be attributed at least 35 patients under this measure to be scored on it.  

For the episode-based cost measures, CMS will continue to use the following attribution methodologies:

  • For acute inpatient medical condition episode-based measures: An episode is attributed to each MIPS eligible clinician who bills inpatient E/M claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30 percent of the inpatient E/M claim lines in that hospitalization. A clinician or group must be attributed a minimum of 20 episodes to be scored on this type of measure.
  • For procedural episode-based measures: Episode is attributed to each MIPS eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes. A clinician or group must be attributed a minimum of 10 episodes to be scored on this type of measure.

The Cost category could be helpful in avoiding a penalty for the 2020 performance period. CMS intends to provide feedback on 2019 cost measure performance data by the summer of 2020, in order for physicians to better understand their cost score. As the cost category weight and overall MIPS performance threshold continues to increase, it becomes increasingly important to understand your previous performance in this category. We recommend becoming familiar with your 2018 and 2019 feedback reports, as they will be good tools to assist in estimating possible scores for cost in 2020 and beyond. You can access performance feedback reports through the QPP website by signing in with your credentials (the same credentials used to submit and review data during the submission period).

For the first time, scoring for the 2019 program year will automatically use the Hospital Value-Based Purchasing (VBP) Program score of a facility-based clinician or group in lieu of a MIPS score if the VBP score is higher than the clinician’s combined Quality and Cost score under MIPS. Learn more about facility-based scoring.

Additional information about each specific 2020 Cost measure is available on the CMS QPP website. CMS also offers a Cost Category fact sheet, which provides more details about the methodology for attributing and scoring these measures.

CMS also offers many resources on their Quality Payment Program website, and is a great resource for learning about and selecting Quality measures, Promoting Interoperability measures, and Improvement Activities for reporting in 2020 .