FY 2018 Proposed QPP Rule Overview

Published Monday, July 3, 2017



Please find below a summary of the major provisions of the proposed CY 2018 Quality Payment Program (QPP) Rule (CMS-5522-P) that was published on June 20. The summary below focuses on the highlights of the rule with an emphasis on cardiology. CMS has also published a 26-page fact sheet that provides details on the current transition year (2017) and their proposed changes for 2018. The link to this fact sheet is included below as it provides useful information in a relatively easy-to-read format.  


CY 2018 Updates to the Quality Payment Program 


High-Level Impact

  • CMS estimates the following related to MIPS:
    • 572,000 eligible clinicians will participate in MIPS
    • $173 million in budget neutral payments will be provided in payment year 2020
    • $500 million is available for Exceptional Performance
  • CMS estimated the following related Qualified Professionals (QPs) who are exempt from MIPS
    • Between 180,000-245,000 eligible clinicians (ECs) will become QPs
    • Incentive payments are estimated to be $590-800 million

Low Volume Threshold – Physicians Excluded from MIPS

  • Increase the low volume threshold for both the amount of Part B billings and the number of Medicare patients. This will serve to exclude more eligible clinicians from MIPS as meeting either threshold triggers exclusion.  CMS is proposing to:
    • Increase the allowed Medicare Part B charge threshold to $90,000 (from $30,000)
    • ECs who see 200 or less Medicare patients (from 100 Medicare patients)
  • Starting in 2019, ECs can opt-in to MIPS if they exceed either of the criteria above
  • CMS is also evaluating a third criteria based on the number of Part B items and services provided, which may include patient encounters or procedures
    • CMS is not making a proposal, but is requesting comments on this third option
    • The number of excluded clinicians from MIPS due to these changes is expected to be 585,600

Practice Designations

  • Small Practices
    • Proposing to change the process to determine small practices from attestation to utilizing claims data
  • Rural Area and Health Professional Shortage Area Practices
    • Proposing to increase the designation threshold to 75% or more of NPIs billing are designated in a zip code as a rural area or HPSA
  • Non-Patient Facing MIPS ECs
    • No significant changes, except CMS will use the same criteria for virtual groups as regular groups


Merit-based Incentive Payment System (MIPS)

Group Reporting

  • No changes for group reporting in 2018
  • CMS is asking for comments on establishing group-related policies that would permit participation in MIPS at a sub-group level and create this via new identifier

Virtual Group (VG) – new option in 2018

  • Allows for two solo practitioners or groups of 10 or fewer ECs to report their Quality and Cost Measures as a group if they choose to (not mandatory)
  • All ECs under a TIN are part of the VG
  • Must make the decision prior to the performance year beginning – by December 1, 2017 for the 2018 performance period
    • Cannot change during the performance year
  • CMS will utilize a MIPS VG participant identified, which is a combination of a VG identifier, TIN and NPI
  • In general, MIPS group policies on measurement, payment, etc., apply the same to a VG
  • VGs would be provided “Small Practice” status if they have 15 or less members
  • Must have formal written agreements for VG participants (CMS has proposed various requirements)
  • Must elect to be in a VG – Two stage election process
    • Stage 1 – CMS will determine eligibility
    • State 2 – VG representative provides various information pertaining to each TIN and NPI associated with the VG and contact information of the VG representative
  • VG election process to be available as early as mid-September, 2017

MIPS Performance Period

  • No changes proposed for 2018

MIPS Submission Mechanisms

  • Proposing to allow for multiple mechanisms to be utilized to report MIPS measures
  • Must use same identifier for all mechanisms
  • Must utilize only 1 method for a performance category
  • Deadlines for submission are not changing

MIPS Weighting of Performance Categories

  • CMS is proposing to leave the weighting of the Cost performance category at 0% for 2018 to allow an additional year for ECs to monitor and receive feedback on this category
    • CMS is asking for comments regarding weighting cost at 10% for 2018 as originally scheduled
    • CMS is concerned because for performance year 2020, the Cost performance category is scheduled to be weighted at 30%
  • No other changes are proposed
    • When Cost is weighted above 0%, the percentage change will be applied to Quality

Performance Category – Quality

  • Proposed new and modified Cardiology and EP specialty sets for 2018 and future years have been included as an Appendix to this memo

Performance Category – Cost

  • CMS will be developing new episode-based measures for the Cost category, and will include them in future rulemaking – no additional proposals at this time
  • No changes to the attribution methodology, although CPT codes 99487 and 99489 are being added to the primary care list for the total per capita cost measure
  • Feedback will continue to be provided to ECs to get them accustomed to the cost measures

Performance Category – Improvement Activities

  • New activities, and various changes have been made for 2018. They are available at Tables F, G and H in the proposed rule
    • CMS is adding consultation of AUC for advanced diagnostic imaging as a “High” weighted activity

Performance Category – Advancing Care Information (ACI)

  • Proposing to allow the use of 2014 or 2015 editions of CEHRT, or a combination of both
    • Will offer a 10% bonus if 2015 edition of CERHT is used throughout 2018
    • Criteria for 2014 and 2015 CEHRT are provided in Table 8 of the proposed rule
  • Various exceptions for ACI
    • Application process – no changes from 2017 exceptions
    • If exception applies, this category will be reweighted to 0%
    • Adding a significant hardship exception for small practices (15 or fewer clinicians and sole practitioner)
    • Adding an exception for ASC-based MIPS ECs that bill 75% or more of their total services in the ASC place of services (POS 24)

Changes to MIPS Scoring Methodology

  • Threshold for MIPS Adjustments
    • Please note threshold to have no negative adjustments increases to 15 points for 2018
  • Quality
    • 3-point floor for any measure scored against a benchmark
    • Measures that do not have a benchmark or don’t meet a case minimum will be scored at 3 points
    • Measures that do not meet data completeness requirements will get 1 point (down from 3 in 2017), except for small practices, which will still receive 3 points
  • Quality / Topped Out Measures
    • For select set of 6 topped out measures, CMS will cap these at 6 points (Table 21 of proposed rule) – none specific to Cardiology
    • Initiating a 3-year process to remove topped out measures from the program
      • Will not apply to CMS web interface measures
  • Improvements in performance in the Quality and Cost performance categories will be added
    • Quality
      • Scored at the performance category level
      • Will be added to the achievement percentage score, and cannot exceed 10%
      • Results will be compared for the same identifier (TIN/NPI) over two consecutive periods
      • If data is insufficient, improvement is scored as 0
    • Cost
      • Scored at the measure level based on statistically significant changes
      • Maximum additional score is 1%
      • If data is insufficient, improvement is scored as 0
      • Note: this will not impact 2018 scoring as this performance category is weighted at 0%
  • Facility Based Measures Scoring Option – Quality and Cost
    • Optional, voluntary mechanism based on Hospital-Based Purchasing program
    • Available only to ECs who have at least 75% of services provided as inpatient or emergency room
    • Converts a hospital total performance score into Quality and Cost scores
  • Complex Patient Bonus
    • Adjustment of up to 3 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to final score
    • Typically, this will award 1 to 3 points
    • CMS is asking for comments of including dual eligibility as a method of adjusting scored as an alternative, or in addition to, the HCC score
  • Small Practice Bonus
    • Add 5 bonus points to ECs in a small practice (15 or fewer clinicians) as long as they submit data in at least 1 performance category
    • CMS is asking for comments if this bonus should be provided to rural areas as well


Advanced APMs

Financial Requirements for Qualification as an Advanced APM

  • Generally Applicable Nominal Amount Standard
    • 8% revenue based standard is extended for two additional years through 2020
  • Medical Home Model
    • Exempt round 1 participants in the CPC+ from the requirement that the medical home standard applies to APM entities with fewer than 50 ECs in their parent organization
    • Minimal total potential risk is adjusted to
      • 2% of estimated average Medicare Part A and B revenues of all providers and suppliers in participating APM entities for 2018
      • 3% for 2019
      • 4% for 2020
      • 5% for 2021 and beyond

All Payer Combination Option

  • CMS is required to develop a process whereby an EC can obtain Qualified Professional (QP) status through participation in qualifying advanced APMs of payers other than Medicare
  • This option will become available in 2019, impacting the 2021 payment year
  • All Payer QP Determination
    • A separate All-Payer QP determination period will be created – January 1 through June 30 of the performance year
    • All-Payer Combination Option QP determinations would be based on 2 periods: January 1 - March 31, or January 1- June 30
  • CMS provides various proposals in this rule on determining which other payer models will qualify as advanced APMs

Identifying MIPS APM Participants

  • CMS will add a fourth snapshot date of December 31 for the purpose of determining participation in full TIN MIPS APMs
    • This date will NOT be used to make QP determinations, which are taken at three earlier dates (March 31, June 30, August 31)

MIPS APM Scoring Methodology – Performance Categories

  • Quality – 50%
  • Cost – 0%
  • Improvement Activities – 20%
  • Advancing Care Information – 30%


Click here to open APPENDIX: Proposed New and Modified MIPS Specialty Measure Sets for 2018 - Cardiology

Click here to open APPENDIX:  Proposed New and Modified MIPS Specialty Measure Sets for 2018 – Electrophysiology