The Centers for Medicare & Medicaid Services (CMS) finalized several updates to meet the participation requirements for year six (2022) of the Quality Payment Program (QPP). Two participation pathways are available in the QPP, either through the Merit-based Incentive Payment System (MIPS) or participation in an Advanced Alternative Payment Model (APM). Starting in 2023, clinicians may choose to participate in MIPS through a MIPS Value Pathway (MVP). If a surgeon participates via traditional MIPS or an MVP, the score will continue to be calculated based on performance in the four MIPS performance categories: Quality, Improvement Activities (IA), Cost, and Promoting Interoperability (PI).1
- Quality: This category aims to measure the quality of the care delivered.
- Improvement activities (IA): This category includes an inventory of activities that aim to assess how clinicians improve care processes, enhance patient engagement in care, and increase access to care, among other activities.
- Promoting interoperability (PI): This category focuses on the use of Certified Electronic Health Record Technology (CEHRT) to manage patient engagement and the electronic exchange of health information.
- Cost: CMS automatically calculates this category based on Medicare claims. MIPS uses cost measures to evaluate the total cost of care during the year, during a hospital stay, or during a specific episode of care for attributed patie2
How can a surgeon determine if they are required to participate in QPP in 2022?
Surgeons can use their National Provider Identification (also known as NPI) numbers in the QPP Participation Lookup tool to determine their QPP eligibility. To be eligible for MIPS, clinicians must exceed the low-volume threshold, which is defined by allowed charges, the number of Medicare patients served, and the number of covered professional services the clinician provides to Part B patients. A clinician who bills more than $90,000 for Medicare Part B covered services, sees more than 200 Part B patients, and provides more than 200 covered professional services to Part B patients will be required to participate in MIPS. Once eligibility is determined, surgeons should understand how their employer or group intends to participate in the QPP and how this situation may have changed since previous years.
What do surgeons need to know about MVPs in 2022?
CMS has finalized a new way to participate in MIPS—the MVPs. The intent of MVPs is to reduce the burden and complexity of selecting from a litany of MIPS measures and activities and to provide a more cohesive and meaningful reporting experience. MVPs will aim to connect activities and measures from the four MIPS performance categories that are relevant to a specific specialty, condition, or population. As a result, CMS intends to provide clinicians and patients with more timely and relevant performance data and help prepare clinicians to transition from fee-for-service to APMs.
Although surgeons do not need to take any action regarding MVPs in the 2022 performance year, CMS will make the following seven MVPs voluntary MIPS participation pathway:
- Stroke care
- Ischemic heart disease
- Chronic disease management
- Emergency medicine
- Lower extremity joint repair
In future years, CMS will propose additional MVPs. The College has advised CMS to model MVPs after a true quality program that focuses overarchingly on the care of the patient, including the goals and outcomes important to the patient, while also valuing the infrastructure, resources, and processes needed to deliver optimal care and improvement. The American College of Surgeons (ACS) is concerned that MVPs—much like MIPS—will fall short of the mark for informing the patient or helping care teams understand quality, safety, and overall outcome attainment for a specific condition or procedure.
As part of the transition to MVPs, CMS also plans to implement voluntary subgroup reporting for clinicians who choose to participate in MVPs or the APM Performance Pathway (APP). The APP is an optional reporting and scoring pathway for surgeons who participate in a MIPS APM that began in 2021. CMS maintains that allowing multispecialty groups to form subgroups will enable specialties to select MVPs that are most relevant to the care they deliver. Starting in 2025, subgroup reporting will be mandatory for multispecialty groups that choose to participate in an MVP.
Are there changes to traditional MIPS in 2022 that surgeons need to know about to avoid a penalty?
In 2022, the MIPS performance threshold increases from 60 to 75 points—a significant increase in the threshold required to avoid a penalty. The performance threshold is the minimum number of points needed to avoid a penalty each year. MIPS-eligible clinicians will receive a total MIPS final score based on performance across the four performance categories—Quality, IAs, Cost, and PI—which is then compared with the MIPS performance threshold to determine the payment adjustment the clinician receives for the associated payment year. MIPS performance in the 2022 performance year will determine a clinician’s MIPS payment adjustment in the 2024 payment year. Therefore, in 2022, MIPS-eligible clinicians must achieve at least 75 points through their performance in the four MIPS performance categories to avoid a negative payment adjustment in 2024. As discussed later in this article, the maximum negative adjustment in 2024 based on 2022 performance is -9 percent.
When calculating MIPS final scores, CMS applies a specific weight to each performance category. Beginning in 2022, to comply with statutory requirements, the Quality category weight will decrease 10 percentage points to 30 percent of the MIPS final score, and the Cost category will increase 10 percentage points to 30 percent of the MIPS final score. The category weights for PI and IA remain unchanged.
In past years, clinicians could focus reporting on one or two MIPS performance categories to achieve the performance threshold; however, this is no longer the case. With the changes to the category weights and the increased performance threshold, it becomes increasingly important to meet the reporting requirements in all three reportable MIPS categories. Because CMS calculates the Cost score based on performance year claims data, it is difficult to predict how a surgeon will score in the cost category ahead of the performance period (see Figure 1).
What is the maximum payment adjustment for the 2022 performance period/2024 payment year?
As determined by the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA), the maximum negative payment adjustment for the 2024 payment year based on 2022 performance is -9 percent. Because MIPS is a budget-neutral program, the total amount of funding available for positive payment adjustments cannot be determined until CMS knows the total amount of negative payment adjustments in any given year. However, the maximum positive payment adjustments to date have not exceeded 2 percent (the payment adjustments were 1.88 percent in 2019, 1.68 percent in 2020, and 1.79 percent in 2021). Also note that MACRA authorized a separate pool of funding, available for the first six years of the program, to reward clinicians with exceptional performance. MIPS participants who exceed the separate exceptional performance threshold are eligible for an additional positive payment adjustment from this separate pool of funding. For the 2022 performance year/2024 payment year, CMS set the exceptional performance threshold at 89 points, up from 85 points. However, 2022 is the last performance year that funding will be available for exceptional performance bonuses. This is an important point because the exceptional performance pool of funding has made up the bulk of positive payment adjustments received by clinicians to date.
Will CMS provide any relief to surgeons who have patients or practices affected by COVID-19?
For the 2019, 2020, and 2021 MIPS performance years, CMS designated the coronavirus 2019 (COVID-19) pandemic as a qualifying event for the Extreme and Uncontrollable Circumstances Hardship Exception during the public health emergency (PHE). The agency stated in a recently released “2022 QPP Final Rule Frequently Asked Questions” document that it anticipates “the extension of the national COVID-19 PHE into 2022, and [has] an established application-based extreme and uncontrollable circumstances policy that will continue for clinicians on the front lines of the PHE.”3 Additional details about the 2022 exception application should be available later in 2022.
Surgeons who have practices that have been disrupted by the pandemic or another hardship in 2022 may submit an Extreme and Uncontrollable Circumstance Hardship Exception application to CMS requesting reweighting of up to all four MIPS performance categories. If clinicians are approved for reweighting of all four performance categories, they will receive a neutral payment adjustment; however, note that data submission will override any reweightings approved through this application on a category-by-category basis, which means they will be scored on those categories.
What is required to meet the performance threshold (75 points) and avoid a payment penalty?
Now that the MIPS performance threshold is set at 75 points and the category weights have been adjusted, surgeons will need to meet the reporting requirements for all three reportable MIPS performance categories (Quality, IA, and PI). CMS automatically calculates Cost scores using claims data, so no data submission is required for this category, but surgeons should review past MIPS performance feedback reports to predict how they could perform in 2022. Surgeons can access past MIPS performance feedback reports by logging into the QPP portal using HCQIS Access Roles and Profile (HARP) credentials.
What is required to achieve the maximum score in Quality performance category?
As in previous years, MIPS participants are expected to report on at least six MIPS quality measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is unavailable*) for the duration of the performance year (12 months).4 To receive a performance score on a measure, clinicians must report quality data for at least 70 percent of all applicable patients (regardless of payor) during the 2022 calendar year.
To achieve full credit for this category, surgeons will need to earn 60 Quality measure points. Each Quality measure is worth up to 10 points, but there are multiple situations in which the points available for a measure are capped below 10 points (for example, if the measure lacks a benchmark, it may only be eligible for 3 points; if classified as “topped out” because of high-performance rates, it may be subject to a 7 point cap), making it more challenging to achieve 60 points for this category. Given that the maximum 10 points may not be available for a number of quality measures, surgeons should view the available benchmarks associated with quality measures that are most relevant to their practice and determine a quality reporting strategy that will help them be successful in this category in 2022. CMS plans to release 2022 Quality measure benchmark files prior to the 2022 performance year.
What is required to achieve the maximum score in the IA performance category?
To receive full credit (15 points toward the final MIPS score), most surgeons must attest to having completed up to four activities in at least 90 consecutive days in the 12-month performance period for a total of 40 points. IAs are classified by medium or high weights; a medium-weighted activity generally accounts for 10 points and a high-weighted activity accounts for 20 points (small practices can earn more points for IAs and, thus, attest to fewer).
It is important to note that requirements vary based on practice size and/or location. For small practices or rural practices to achieve full credit, only one high-weighted activity (worth 40 points) or two medium-weighted activities (worth 20 points each) is required. CMS defines small practices as those with 15 or fewer MIPS-eligible clinicians. CMS defines rural practices as those in which more than 75 percent of the NPIs billing under the individual MIPS-eligible clinician or group’s Taxpayer Identification Number (TIN) are designated in a ZIP code as a rural area or health professional shortage area based on the most recent Health Resources and Services Administration Area Health Resource File data set.
If participating in MIPS as a group (TIN-level), practices may only attest to an IA if at least 50 percent of the clinicians in the group or virtual group complete the same activity during any continuous 90-day period in the performance year.
What is required to achieve the maximum score in the MIPS PI performance category?
To receive credit for the PI category in 2022, the following activities must be completed:
- Use “2015 edition” (or the updated 2015 edition described later in this article) certified electronic health record technology (CEHRT)
- Report performance for 90 continuous days or more
- Attest “yes” or “no” to conducting an annual assessment of the High Priority Guide of the Safety Assurance Factors for EHR [Electronic Health Record] Resilience Guides (SAFER Guides)
- Answer “yes” to completing the Prevention of Information Blocking attestations
- Answer “yes” to ONC (The Office of the National Coordinator for Health Information Technology) Direct Review Attestation (if applicable)
- Answer “yes” to completing the Security Risk Analysis (SRA) measure
- Report data for all measures under each of the four objectives or claim an exclusion, if applicable
Reporting in the PI category is “all or nothing,” meaning that a numerator and denominator must be reported for all objectives to be eligible for a score in this category.
As in the past, clinicians who meet CMS’ definition of “Ambulatory Surgery Center-based” or “hospital-based” will be automatically exempt from the PI category in 2022. More information about these definitions can be found here. For those clinicians who qualify for this exemption, CMS will reweight the PI category to 0 percent and the 25 percent weight of the category will be redistributed to another category (typically Quality). For example, if a hospital-based clinician is scored on all other performance categories except for PI, the weight of that category will be shifted to the Quality category (becoming 55 percent rather than 30 percent), thus increasing the contribution of a clinician’s Quality performance to his/her final MIPS score.
Beginning in 2022, surgeons who meet the criteria for the small practice designation also will receive an automatic reweighting of the PI performance category. In the past, clinicians in small practices were required to submit an application to qualify for this exemption. If no data are submitted by or on behalf of the small practice for the PI category at the end of the performance period, CMS will automatically reweight the PI category to 0 percent and redistribute its weight to another performance category or categories. If a small practice does submit data for the PI category during the performance year, the data will be scored the same as all other MIPS-eligible clinicians.
Has CMS made any changes to the CEHRT required to participate in the MIPS Promoting Interoperability category and reporting eCQMs?
The PI category focuses on how clinicians use CEHRT to manage patient engagement and the electronic exchange of health information. To receive a score in PI, use of technology that is considered certified under the Office of the National Coordinator (ONC) for Health IT’s (Information Technology’s) Certification Program is required. Changes to the version of CEHRT that is required for 2022 have been made, and surgeons can continue to participate in the PI category using “2015 Edition” CEHRT. Although ONC recently finalized an updated EHR certification criteria to better promote interoperability, known as the “2015 Edition Cures Update,” in the 21st Century Cures Act final rule†, MIPS-eligible clinicians and groups are not required to use the updated version until 2023.5 Health IT developers have until December 31, 2022, to offer technology that is certified to meet the updated criteria; therefore, clinicians participating in MIPS may use EHRs certified to either the existing 2015 Edition or updated 2015 Edition Cures Update certification criteria until December 31, 2022.
If a clinician is reporting on electronic clinical quality measures (eCQMs) and their practice schedules a transition from one EHR system to another during the 12-month MIPS performance period, they still must meet the 70 percent data completeness threshold and 12-month performance period criteria. CMS suggests running and supplying a report in the EHR system that is being phased out before the transition to the new EHR system and aggregating the data into a single 12-month report for submission to CMS.
In recent years, the ACS has advocated for CMS to transition the PI program beyond EHR-centric data exchange toward true interoperability.‡ With the rapid pace at which health care technology is advancing, the College recommends that CMS begin considering how to reward and measure clinicians’ knowledge sharing and knowledge engineering digital services, instead of focusing solely on measuring the functionality of EHRs.
Will CMS continue to offer opportunities for bonus points in 2022?
Beginning in 2022, CMS will no longer offer bonus points for reporting additional outcome or high-priority quality measures, or for end-to-end EHR reporting. However, the improvement scoring policy will continue throughout the 2022 performance period/2024 payment year. Up to 10 additional percentage points can be earned if performance in the Quality category as a whole improved in 2022 as compared with 2021.
In 2022, CMS adopted a revised complex patient bonus to better target clinicians who serve a higher share of dual-eligible Medicare/Medicaid and/or medically complex patients. Under this modified methodology, clinicians can earn up to 10 bonus points.
If surgeons participate in MIPS through an employer, but in previous years was not required to report surgical measures, do they need to do anything different under the 2022 rule?
As discussed previously, each year it is important for surgeons to determine their MIPS eligibility status, regardless of participation or nonparticipation in previous years.
Because clinicians may participate in MIPS at the TIN level, surgeons in larger groups (or employed by larger institutions) may have previously satisfied QPP requirements without even knowing it or having taken any action. Some larger groups rely on the CMS Web Interface to report quality measures, which allows groups to submit a specified set of quality measures (mostly primary care-focused) on a sample of their patients. Although the Web Interface will remain an option for large groups in 2022, CMS has decided to retire it in 2023 (2025 for Medicare Shared Savings Program Accountable Care Organizations [ACOs]); hence, groups that have relied on it in the past will need to select a different reporting strategy. It is recommended that surgeons consult their group practice administrator to determine whether and how it intends to report on their behalf in 2023 and beyond.
Are surgeons in APMs required to participate in MIPS?
Qualifying Participants (QPs) in an Advanced APM are clinicians who participate sufficiently in an APM, qualify for a 5 percent lump-sum incentive payment, and are exempt from MIPS. The 2022 performance period is the last year to qualify for the 5 percent APM payment incentive, payable in 2024.
Note that the thresholds for qualifying for QP status will remain the same from the 2021 performance period to the 2022 performance period.
If a clinician participates in a MIPS APM, but not at a volume to achieve QP status, participation in MIPS will still be necessary to avoid a penalty. Until 2020, clinicians in this situation were generally scored at the APM Entity level under the APM Scoring Standard.
In 2021, CMS retired the APM Scoring Standard but offered the new APP. Clinicians in MIPS APMs may participate in the APP or traditional MIPS at the individual, group, virtual group, or APM Entity level in 2022. However, reporting requirements and scoring accommodations will depend on which track is selected. Note that Shared Savings Program ACOs must report through the APP, but may report on the Web Interface set in place of certain APP measures until 2024.
Surgeons can use the QPP Participation Lookup tool to determine if they are considered a QP or required to participate in MIPS in 2022.
The ACS offers more detailed information about how to successfully report to the QPP in 2022, in the ACS QPP Resource Center. For further information and guidance about QPP reporting, contact Haley Jeffcoat, ACS Quality Affairs Associate, at firstname.lastname@example.org.
*High-priority measures are measures that fall within the following categories, as designated by CMS: outcome (includes intermediate outcome and patient-reported outcome measures), appropriate use, patient experience, patient safety, efficiency measures, care coordination, and opioid-related quality measures.
†The Cures Act Final Rule implements interoperability requirements outlined in the 21st Century Cures Act, which was designed to assist in the acceleration of medical product development and bring new innovations and advances to patients who need them faster and more efficiently.
‡The ability of different information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner, within and across organizational, regional, and national boundaries.
- Centers for Medicare & Medicaid Services. Physician fee schedule. CY 2022 Medicare Physician Fee Schedule Final Rule. Available at: https://www.federalregister.gov/public-inspection/2021-23972/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part. Accessed November 17, 2021.
- Centers for Medicare & Medicaid Services. Quality Payment Program. MIPS overview. Available at: https://qpp.cms.gov/mips/overview. Accessed November 17, 2021.
- Centers for Medicare & Medicaid Services. 2022 Quality Payment Program (QPP) Final Rule Frequently Asked Questions (FAQs). Available at: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/1654/2022%20Quality%20Payment%20Program%20Final%20Rule%20Resources.zip. Accessed November 17, 2021.
- Centers for Medicare & Medicaid Services. Quality Measures: Traditional MIPS Requirements. Available at: https://qpp.cms.gov/mips/quality-measures. Accessed November 17, 2021.
- The Office of the National Coordinator for Health Information Technology. ONC’s Cures Act Final Rule supports seamless and secure access, exchange, and use of electronic health information. Available at: https://www.healthit.gov/curesrule/. Accessed November 17, 2021.