The Cost performance category is worth 30 percent of the Merit-based Incentive Payment System (MIPS) final score in 2023.
There are no reporting requirements for the Cost performance categories.
The Centers for Medicare and Medicaid Services (CMS) will automatically calculate cost measures for the 2023 performance period based on claims data.
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.
MIPS-eligible clinicians who participate in certain types of APMs, but do not participate sufficiently to qualify for the APM track of the QPP are still required to participate in MIPS and may do so at the APM Entity level. Therefore, a surgeon who participates in MIPS APMs and reports to traditional MIPS as individuals, groups, or virtual groups will be scored on cost. However, surgeons in a MIPS APM that reports to traditional MIPS at the APM Entity level will not be scored on cost. Instead, the cost performance category will be reweighted to 0 percent under traditional MIPS if the APM Entity reports quality and improvement activity data. The cost category will also be reweighted for clinicians who report via the new APM Performance Pathway (APP), either as an individual, group, or MIPS APM Entity. Download more information about the APP.
Cost measures that will be used in 2023 include The Total Per Capita Cost (TPCC) for all attributed Medicare Beneficiaries measure, the Medicare Spending per Beneficiary (MSPB) measure, and multiple episode-specific cost measures. The 23 episode-based cost measures available in 2023 are listed below:
- Acute Kidney Injury Requiring New Inpatient Dialysis
- Asthma/Chronic Obstructive Pulmonary Disease (COPD)
- Colon and Rectal Resection
- Diabetes
- Elective Outpatient Percutaneous Coronary Intervention (PCI)
- Elective Primary Hip Arthroplasty
- Femoral or Inguinal Hernia Repair
- Hemodialysis Access Creation
- Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
- Intracranial Hemorrhage or Cerebral Infarction
- Knee arthroplasty
- Lower Gastrointestinal Hemorrhage (groups only)
- Lumbar Spine Fusion for Degenerative Disease, 1-3 levels
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
- Melanoma Resection
- Non-Emergent Coronary Artery Bypass Graft (CABG)
- Renal or Ureteral Stone Surgical Treatment
- Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Routine Cataract Removal with Intraocular Lens Implantation
- Screening/Surveillance Colonoscopy
- Sepsis
- Simple Pneumonia with Hospitalization
- ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)
It is more likely that surgeons could be attributed to the MSPB measure than the TPCC measure based on the attribution methodologies. The MSPB measure assesses Medicare Part A and B costs related to the care provided to a beneficiary during an episode defined as three 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.
CMS intends to provide feedback on 2022 cost measure performance data by the summer of 2023, in order for physicians to better understand their cost score. Now that the MIPS overall performance threshold and the weight of the Cost category has increased, it is important to understand your previous performance in this category. We recommend becoming familiar with your past feedback reports, as they will be good tools to assist in estimating possible scores for cost in 2023 and beyond. However, keep in mind that there may be discrepancies in your Cost data in recent years due to disruptions caused by the COVID-19 pandemic. 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).
Improvement Scoring in Cost
Last year, CMS established a maximum cost improvement score of 1 percentage point out of the 100 percentage points available for the cost performance category.
How does facility-based scoring apply to the Cost Category?
If you meet the definition of a facility-based clinician or group, CMS may use your FY 2024 Hospital Value-Based Purchasing (VBP) Program score in lieu of a MIPS score if the VBP score translates to a higher score than the clinician's combined Quality and Cost score under MIPS.
This policy can only help clinicians earn a higher score and does not require any special action or election on the part of the facility-based clinician.
Additional information about the cost category, including a Quick Start Guide and more detailed specifications for each measure, are available through the QPP Resource Library. CMS also offers a 2023 MIPS Cost User Guide and 2023 Cost Quick Start Guide, which provides more details about the methodology for attributing and scoring these measures.
