The 2019 Medicare Documentation, Coding, and Payment Update

Kent Moore; Amy Mullins, MD, CPE, FAAFP; Erin Solis; Barbara Hays, CPC, CPMA, CPC-I, CEMC


Fam Pract Manag. 2019;26(1):23-28. 

In This Article

Quality Payment Program (QPP) Changes

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which established the QPP and its two tracks for physician payment under Medicare: Merit-based Incentive Payment (MIPS) and Advanced Alternative Payment Models. Jan. 1, 2019, marks the first year physicians participating in MIPS will see their Medicare payments adjusted, positively or negatively, based on the 2017 QPP performance year.

The 2019 requirements. In February 2018, the Bipartisan Budget Act of 2018 (BBA) granted CMS additional flexibility in how it implements the QPP, which CMS used as it finalized policies for the 2019 QPP performance year. (See "The 2019 MIPS requirements at a glance.")

First, the BBA provided a slower transition to full accountability for physicians for the MIPS cost performance category. Initially, MACRA required the cost category to account for 30 percent of the MIPS final score in performance year 2019. The BBA allows CMS to set the weight of the cost category between 10 percent and 30 percent during performance years 2019 to 2021 and requires a weight of 30 percent in performance year 2022. For performance year 2019, CMS has increased the weight of the cost performance category from 10 percent to 15 percent and decreased the weight of the quality category from 50 percent to 45 percent. The "promoting interoperability" category (formerly known as "advancing care information") remains at 25 percent, and improvement activities remain at 15 percent.

Second, the BBA authorized a more gradual increase in the performance threshold, that is, the minimum number of points a physician must earn to avoid a negative payment adjustment. MACRA required the performance threshold to be either the mean or median of the previous year's MIPS scores by performance year 2019. The BBA allows CMS to gradually increase the threshold during performance years 2019 to 2021 and transition to the mean or median by 2022. To avoid a negative 7 percent payment adjustment in 2021 (based on performance in 2019), participants must meet or exceed the MIPS performance threshold of 30 points this year, up from 15 points in 2018. The exceptional performance threshold has increased from 70 points to 75 points.

Third, the BBA made changes to the low-volume threshold calculation, which determines whether a physician is excluded from a MIPS payment adjustment due to a low volume of beneficiaries or allowed charges. Previously, low-volume threshold determinations were made using all Medicare Part B allowed charges, including Part B medications and Part B services not paid under the Medicare physician fee schedule. The BBA removed Part B medications and any services not paid under the fee schedule from the low-volume calculation, which began with performance year 2018 (i.e., payment year 2020).

In addition, CMS has added one criterion, number of professional services, to the threshold in 2019. A physician is now below the low-volume threshold if he or she does any of the following:

"Jan. 1, 2019, marks the first year physicians participating in MIPS will see their Medicare payments adjusted, positively or negatively, based on the 2017 QPP performance year."
  • Has <$90,000 in Part B allowed charges for covered professional services,

  • Provides care to <200 Medicare Part B beneficiaries,

  • Provides <200 covered professional services to Medicare beneficiaries.

Any eligible clinician who meets the low-volume threshold exclusion has the option to opt-in and participate in MIPS if he or she meets or exceeds one or two of the low-volume threshold criteria. These opt-in participants will be eligible for both positive and negative payment adjustments.

Lastly, the BBA changed how the MIPS payment adjustments get applied. Prior to the BBA, MIPS payment adjustments, both positive and negative, applied to all items and services under Medicare Part B (such as medications). Now, payment adjustments will only apply to covered professional services paid under the Medicare physician fee schedule.

One notable "nonchange" is the stability of the performance periods. For performance year 2019, quality and cost will continue to be measured for one year. Improvement activities and promoting interoperability require 90 consecutive days of reporting.

Bonus points. In 2019, Medicare will add six bonus points to the quality score of any eligible clinician in a small practice (15 or fewer clinicians billing under a single tax identification number). This differs slightly from performance year 2018, when CMS added five bonus points to the MIPS final score.

Small practices will continue to receive three points for all quality measures reported, regardless of whether they meet the data completeness criteria. All other practices will receive one point for measures that do not meet data completeness.

CMS will add up to five bonus points to the final score of any size practice based on the care of complex patients. CMS calculates this score using the average hierarchical condition categories score of the patient panel and percentage of dual-eligible (having both Medicare and Medicaid) patients.

Small practice options. In addition to offering small practice bonuses, CMS is allowing small practices these options:

  • Submit data for covered professional services using Medicare Part B claims (as opposed to using a registry, EHR, or the CMS web interface) for the "quality" performance category,

  • Apply to receive a reweighting of the "promoting interoperability" performance category (with the 25 percent added to the quality performance category) if they have issues acquiring an EHR,

  • Participate in MIPS as a virtual group,

  • Receive no-cost, customized support through the Small, Underserved, and Rural Support technical assistance initiative.