MIPS 2019 Proposed Rule: What pathologists should watch for

July 26, 2018

While many groups have yet to fully turn their attention to fulfilling their 2018 Merit-based Incentive Payment System reporting requirements, CMS already has an eye on the 2019 reporting year and beyond. A number of changes for the program were recently proposed along with the 2019 Medicare Physician Fee Schedule Proposed Rule, although could still be revised before the agency releases the final rule late this fall.

For now, here’s a breakdown of the most significant proposals to keep on your radar:

Claims-based reporting finally being phased out

• CMS stated its intention to eventually eliminate the Medicare Part B claims-based reporting process in 2017, so it’s no surprise to learn the agency is proposing to restrict the process to small groups of 15 or fewer physicians next year. That means those in large groups who have relied on claims reporting in the past will need to seek out another method to submit their quality data, such as a qualified reporting registry.

Category weighting remains stable for non-patient facing specialists2019 mips categories

• Fortunately, the proposed rule has not changed the definition of non-patient facing specialists or altered the reporting exemptions offered to these providers since the inaugural MIPS reporting year in 2017. That means most pathologists will again receive 85 percent of their overall MIPS score through their quality reporting, while the final 15 percent can be earned by attesting to one high-weighted or two medium-weighted improvement activities. Non-patient facing specialists will again be exempt from the new Promoting Interoperability (formerly Advancing Care Information) and Cost categories.

Pathology claims-based quality measures set to be retired

• As part of the move away from claims-based reporting, CMS is also attempting to retire a number of quality measures it considers to be topped-out (ie: have a very strong reporting rate, leaving little room for qualitative judgement between physician submissions). Of the eight existing measures in the pathology specialty measure set, the following three were proposed for elimination:

measure changes

What does this mean for the average group? If you’re a small group who plans to continue reporting via claims, you’ll have three fewer available options to report on in the Quality category. While MIPS typically requires participants to report on six quality measures, specialists with a limited selection are only required to report on measures that apply to them.

However, those reporting via the College of American Pathologists Pathology Quality Registry will have access to its expanded selection of quality measures that are available because of the registry’s status as a Qualified Clinical Data Registry.

Payments and bonuses increase along with performance threshold
• While this is set in stone by MACRA legislation, it’s important to remember the stakes of successfully reporting will again be ramped up. Physicians can earn a bonus or penalty of up to 7 percent in the 2021 payment year based on their participation in the 2019 MIPS reporting year. However, CMS is also proposing to raise the bar to avoid a penalty from 15 points to 30 points, meaning a stronger score would be required to enter bonus territory than in years past.


Addition of facility-based scoring mechanism

• For the first time, CMS is proposing to allow some facility-based groups to receive a collective quality score for their hospital rather than requiring them to report through the traditional claims or registry process. The score would be based off the Hospital Value-Based Purchasing Program and would require any participating group to perform 75 percent or more of their covered professional services at that location. This option would be available to those working in the following places of services:

–POS 21 (Inpatient Hospital)
–POS 22 (On-Campus Outpatient Hospital) *
–POS 23 (Emergency Room)
*At least one service must be reported with POS 21 or 23 to be eligible for this method.

Changes to calculation of low-volume threshold

• Currently, the low-volume payment threshold of $90,000 annually applies to all Part B payments. CMS is now proposing to alter this to allow only covered services under the Medicare Physician Fee Schedule to count toward that threshold, meaning some who were required to report this year may not be obligated to do so in 2019.

Beyond that, the agency is considering an additional participation threshold which would require an individual to provide 200 professional services covered under the MPFS. This would be addition to the aforementioned $90,000 payment threshold and the existing requirement of providing care to 200 Medicare patients. A physician is only required to participate if he/she exceeds all three of these thresholds, so again, some who had to report in 2018 may have to do so next year.

The distinction between total patients and services may seem like an odd one, but CMS explained the extra step as a way to acknowledge that multiple services may be provided to one patient.

2019 low volume thresholds

Option to opt-in

• That being said, anyone who was disappointed in the past after missing out on the opportunity to receive a Medicare bonus because they were exempt will be pleased to hear CMS is expected to open up an opt-in process for individuals or groups who exceed one or two, but not all three of the low-volume thresholds. Once a physician opts in, they’ll be eligible to report and be scored like all other MIPS participants.

Updates for Alternative Payment Model participation

• As with past years, providers can again avoid the traditional MIPS reporting track if they participate in one of CMS’s approved Alternative Payment Models, such as an accountable care organization or the Medicare Shared Savings Program. However, CMS is proposing to increase a few requirements for the track, including:

–Continuing to require an 8 percent revenue-based financial risk.
–Increase the percentage of physicians required to use certified EHR tech from 50 to 75 percent.
–Increase opportunities to utilize the APMs for other payers.


While CMS isn’t proposing any radical changes for MIPS participation in 2019, it’s important to begin considering how you could be directly affected. If you’re a large group reporting quality data via claims this year, you may want to start looking for a registry partner to assist with your 2019 reporting since you’ll no longer be able to utilize the claims method. Also, groups who previously relied on the quality measures that are slated to be retired will want to see which of the remaining measures are still applicable to your group.

Finally, make sure you develop a game plan for hitting the proposed 30-point performance threshold required to avoid the 7 percent penalty in 2021. Bonuses are nice, but there is absolutely no excuse for voluntarily accepting a penalty when you have the ability to avoid it with relatively minimal effort.

If you have questions about concerning how to maximize your MIPS bonus, feel free reach out to us directly at 517-486-4262. You may also reach out to Vachette President Mick Raich at 517-403-0763 or at mraich@vachettepathology.com.

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