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PTs, OTs and SLPs in Private Practice Confirmed as Eligible Providers in MIPS

As confirmed in the CY 2019 Medicare Physician Fee Schedule Final Rule released 11/1/2018, PTs, OTs, SLPs, clinical psychologists, dietitians, and audiologists have been added as eligible clinicians to participate in the Merit-based Incentive Payment System (MIPS) for the 2019 performance year (i.e., the 2021 payment year). PTs, OTs, and SLPs in private practice are considered eligible providers for participation in MIPS in 2019. Therapists providing outpatient/Medicare Part B services in a hospital, SNF, or other institutional setting (i.e., providers who bill services on a UB-04) are not eligible to participate.

MIPS is one of two quality payment incentive programs CMS developed to comply with MACRA, the Medicare and CHIP Reauthorization Act of 2015. MIPS applies to clinicians deemed “eligible” by CMS who bill Medicare Part B via professional claims (i.e., CMS 1500/837p) and meet the low-volume threshold (described further below).

Performance under MIPS is measured through data reported to CMS by eligible clinicians, either individually or as a group, in four categories:

  • 1. Quality
  • 2. Improvement Activities
  • 3. Promoting Interoperability
  • 4. Cost

Each category is scored separately, weighted and combined to produce a total/final score. Based on this score, clinicians receive a payment adjustment (either positive or negative) based on their performance.

Under MIPS, clinicians are included if they are an eligible clinician type and meet the Low Volume Threshold. Clinicians are identified for MIPS by a unique TIN (Tax Identification Number) and NPI (National Provider Identifier) combination, if reporting as an individual clinician, or by the TIN, if reporting as a group.

Eligible clinicians (or groups) who meet the low-volume threshold (applied at the TIN/NPI level for individual reporting and the TIN level for group reporting) are required to participate in MIPS. For CY 2019, the low-volume threshold is defined as those clinicians or groups who:

  • 1. Provided ≤ $90,000 in allowed charges for covered professional services; and
  • 2. Treated ≤ 200 Part B-enrolled individuals with services furnished under Medicare Physician Fee Schedule; and
  • 3. Rendered ≤ 200 covered professional services (this item is new for 2019) during the determination period.

The low-volume threshold determination period is a 24-month assessment period consisting of:

  • 1. An initial 12-month segment from 10/1/2017 through 9/30/2018 with a 30-day claims run-out; and
  • 2. A second 12-month segment from 10/1/2018 through 9/30/2019 (with no 30-day run-out).

An individual clinician or group who is identified as not exceeding the low-volume threshold during the first segment will continue to be excluded from MIPS for the applicable performance year, regardless of the results of the second 12-month segment.

In the Final Rule, CMS finalized an “Opt-in Policy,” which allows eligible clinicians (or groups) who exceed the low-volume threshold on at least one but not all three criteria to opt-in to MIPS to be measured on performance (and potentially receive a payment incentive). If a MIPS-eligible clinician does not meet at least one criterion, they are excluded. The low-volume threshold is automatically applied at the individual clinician level. Should a clinician elect to participate in MIPS as a group, the threshold is applied to the volume of services provided by the group.

Therapists who do not meet the low-volume threshold and choose not to opt-in to the program will be able to report MIPS data voluntarily without being subject to the payment adjustment.

Eligible clinicians who are not required to participate (i.e., who do not exceed all three elements of the low-volume threshold), should consider their options and make an informed business decision, weighing the potential to earn incentives with the risk for penalties.

Clinicians and groups may report Quality Measures under MIPS in one of the following ways: Direct, Login, and Upload, via the Medicare Part B Claim, or via the CMS Web Interface (available for groups of >25 eligible clinicians). In 2019, only small practices (≤ 15 eligible clinicians) may utilize the Med B Claims method of reporting available – regardless of whether reporting as an individual clinician or as a group. This method limits the number of quality measures available for reporting.

To meet reporting thresholds for Quality in CY 2019, eligible clinicians participating in MIPS must report at least six measures, including at least one outcome measure, on ≥ 60% of all eligible patients, regardless of payer, if using a reporting method other than via the claim. If utilizing claims-based reporting, data must be submitted on ≥ 60% of eligible Medicare Part B patients. If an outcome measure is not available, clinicians must report another “high priority” measure. If fewer than 6 measures apply, clinicians must report on all available measures.

The Final Rule lists the following MIPS Clinical Quality Measures (CQMs) for PTs and OTs in 2019:

Measures 128, 130, 131, and 182 are claims-based measures which can be reported either via the Medicare Part B claim or via another reporting method (e.g., direct, log in and upload). Measures 217-223 are FOTO measures which cannot be reported via the claim. The FOTO measures are Outcome measures; all of the other measures – except for BMI – are considered “high priority measures.”

The proposed composite Falls Measure was not finalized for MIPS in 2019, leaving only four non-FOTO measures available for PTs and OTs in 2019. And, specific measures for SLPs are not listed or described in the Final Rule.

In addition to the Quality category, MIPS-eligible PTs, OTs and SLPs must report Improvement Activities in 2019. Eligible clinicians or groups must attest to completing Improvement activities for at least a continuous 90-day period during the 12-month performance period (CY 2019). There are more than 100 activities for clinicians to choose from in nine subcategories:

  • 1. Expanded Practice Access
  • 2. Population Management
  • 3. Care Coordination
  • 4. Beneficiary Engagement
  • 5. Patient Safety and Practice Assessment
  • 6. Participation in an Alternative Payment Model (APM)
  • 7. Achieving Health Equity
  • 8. Emergency Preparedness and Response
  • 9. Integrated Behavioral and Mental Health

Activities are categorized as “high-weighted” or “medium-weighted” based on the amount of time and resources it takes to implement and complete the activity. Improvement activities are by default medium-weighted unless specific criteria for high-weighting have been met.

Improvement Activities may be submitted via the Direct, Login, and Upload, or Login and Attest options. Regardless of the method of submission, eligible clinicians submit a “yes” response for each activity performed for at least a continuous 90-day period during the performance period.

For the 2021 payment year (the 2019 performance year), CMS will weigh the 4 MIPS categories as follows:

CMS confirmed they will assign a 0% weighting for the Promoting Interoperability and Cost categories for newly-eligible clinicians in 2019 and will redistribute this 40% to the Quality category, making Quality worth 85% and Improvement Activities 15% for PTs, OTs, and SLPs who participate in 2019.

It is anticipated that most outpatient PTs and OTs would have the ability to opt-in to MIPS in 2019. And, with the potential for a +/- 7% payment adjustment in 2021 based on performance on both Quality and Improvement Activities in 2019, clinicians must carefully consider their options.

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