CY 2018 Quality Payment Program (QPP) Final Rule Overview

News | Published: Monday, November 20, 2017 7:00 am


MedAxiom and the Cardiology Advocacy Alliance have prepared a summary report of the major provisions of the final CY 2018 QPP Rule (CMS-5522-FC) that was published on November 9. Our summary below focuses on the highlights of the rule with an emphasis on cardiology.

CY 2018 Updates to the Quality Payment Program



  • CY 2018 is the performance year that will impact CY 2020, which is the payment year
    • Adjustments for MIPS will be +/- 5% in 2020 based on 2018 performance
  • CMS estimates the following related to MIPS:
    • 622,000 eligible clinicians (ECs) will participate in MIPS
    • $118 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) that are exempt from MIPS, and will receive a 5% lump sum payment
    • Between 185,000-250,000 ECs will become QPs
    • Incentive payments are estimated to be $675-$900 million

Low Volume Threshold – Physicians Excluded from MIPS

  • CMS increased the low volume threshold for both the amount of Part B billings and the number of Medicare patients:
    • Allowed Medicare Part B charge threshold increased to $90,000 (from $30,000), or
    • ECs who see 200 or less Medicare patients (from 100 Medicare patients)
  • CMS had proposed allowing low volume ECs to opt-into MIPS – however, this policy was not finalized and not available in 2018
    • CMS is requesting comments on ways to implement an opt-in policy
  • The number of excluded clinicians from MIPS due to these changes is expected to be 540,000

Practice Designations

  • Small Practices
    • CMS will utilize claims data to determine small practices based on a 12-month assessment period consisting of claims that span from the last 4 months of a calendar year 2 years prior to the performance period + 8 months of the next calendar year
    • CMS anticipates providing MIPS ECs with their small practice size determination by Spring 2018, for the applicable 2018 performance period
  • Rural Area and Health Professional Shortage Area Practices (HPSA)
    • Finalized the proposal 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
    • Patient-facing encounter codes are used to determine the non-patient facing status of ECs
    • List of these encounter codes for 2018 will be available at by the end of 2017

Merit-based Incentive Payment System (MIPS)

Group Reporting

  • No changes for group reporting in 2018
  • CMS had requested comments on establishing group-related policies that would permit participation in MIPS at a sub-group level, and will consider them in future rulemaking

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
  • For 2018, the decision to participate in a VG must be made prior to the performance year beginning (December 31, 2017)
    • Cannot change during the performance year
  • CMS will utilize a MIPS VG participant identifier, 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, and CMS has various requirements for these agreements
  • Must elect to be in a VG – Two-stage election process
    • Stage 1 (optional) – Engaging in Stage 1 provides solo practitioners and groups with the option to confirm whether they are eligible for VG before going through the entire qualification process, including developing written formal agreements
    • State 2 – Eligibility determination, and formal requirements must be provided to CMS to make their determination
  • VG election process for 2018 is available from October 11 – December 31, 2017

MIPS Performance Period

  • No changes proposed for 2018

MIPS Submission Mechanisms

  • ECs and Groups may submit via multiple mechanisms
    • Must use same identifier for all mechanisms
    • Must utilize only 1 method for a performance category
  • CMS is evaluating allowing multiple reporting mechanisms for the same performance category beginning in 2019

MIPS Weighting of Performance Categories

Performance Category

Performance Year



2019 and Beyond









Improvement Activities




Advancing Care Information





  • While CMS proposed to leave the weighting of the Cost performance category at 0% for 2018, they finalized 10% to ease the transition to 2019 and beyond when Cost will equal 30%


Changes to MIPS Scoring Methodology

  • Threshold for MIPS Adjustments
    • Please note the threshold for no negative adjustments increases to 15 points for 2018

2017 Performance Year

2018 Performance Year

Final Score Points

2019 Payment Adjustment

Final Score Points

2020 Payment Adjustment






















Performance Category – Quality

  • New and modified Cardiology and EP specialty sets for 2018 and future years have been included as an Appendix to this memo
  • 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
  • Data completeness is increased to 60% (from 50%), except for Web Interface and CAHPS
  • Ability to score bonus points remains unchanged
  • Quality/Topped Out Measures
    • For select set of 6 topped out measures, CMS will cap these at 7 points (Table 18 of final 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

Performance Category – Cost

  • Two measures will be used for this performance category
    • Total Per Capita Cost
    • Medicare Spending per Beneficiary (MSPB)
  • CMS will be developing new episode-based measures, and will include them in future rulemaking
  • 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

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 bonus of 1% out of 100%
      • If data is insufficient, improvement is scored as 0

Performance Category – Improvement Activities

  • New activities, and various changes have been made for 2018 for these activities:
    • Table F – New Improvement Activities
    • Table G – Improvement Activities with Changes
  • CMS added consultation of AUC for advanced diagnostic imaging as a “High” weighted activity
    • ECs attest they are consulting applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services ordered on/after Jan 1, 2018

Performance Category – Advancing Care Information (ACI)

  • CMS finalized the use of 2014 or 2015 editions of CEHRT, or a combination of both
  • Reporting period remains a minimum of 90 continuous days
  • Bonuses Available
    • Performance score bonus of 10% is available for reporting to any single public health agency or clinical data registry
    • A 5% bonus score is available for submitting to an additional public health agency or clinical data registry not reported under the performance score
    • 10% bonus if 2015 edition of CERHT is used throughout 2018
    • Additional Improvement Activities are eligible for a 10% ACI bonus if CEHRT is used to complete at least 1 of the specified Improvement Activities
  • Various exceptions for ACI
    • Application process – no changes from 2017 exceptions
    • If exception applies, this category will be reweighted to 0%
    • Added a significant hardship exception for small practices (15 or fewer clinicians and sole practitioner)
    • Added an exception for ASC-based MIPS ECs that bill 75% or more of their total services in the ASC place of services (POS 24)

Other Scoring Adjustments

  • Facility Based Measures Scoring Option – Quality and Cost
    • Optional, voluntary mechanism based on Hospital Value-Based Purchasing program that will begin in 2019 (not in 2018 as proposed)
    • Available only to Facility Based ECs
    • 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 and Dual Eligible Patient ration to final score
    • Typically, this will award 2.52-3.72 bonus points
  • 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

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
      • 5% 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
    • QP determinations will be based on three snapshot dates – March 31, June 30, August 31
    • ECs can be assessed at the individual level or APM entity level
  • CMS provides various options in 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%

Virtual Groups and MIPS APMs

  • CMS waived requirements that Virtual Group participants receive their MIPS payment adjustment based on the Virtual Group score
  • Participants in MIPS APMS who are also participating in a Virtual Group will receive their MIPS payment adjustment based on their EPM Entity score under the APM scoring standard


Download: Proposed New and Modified MIPS Specialty Measure Sets for 2018 - Cardiology and Electrophysiology





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