On January 1, 2019, the Centers for Medicare and Medicaid Services is adding physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) in private practice as eligible clinicians for the Merit-Based Incentive Payment System (MIPS) program. MIPS streamlines three existing programs (PQRS, Value-Based Payment Modifier, and Electronic Health Records Incentive Program) and adds one new component (Improvement Activities). In 2017 and 2018, PTs, OTs, and SLPs in private practice were not eligible to participate in MIPS, but this all changes on January 1, 2019.
MIPS only applies to PTs, OTs and SLPs in the private practice setting. The easiest way to know if you are a private practice is if you submit claims to the Medicare program on a 1500-claim form. If you’re not in private practice, you submit claims on a UB-04 claim form and are not eligible to participate in MIPS.
Below are common questions and answers surrounding MIPS:
1. In calendar year 2019, which professionals will be considered eligible clinicians for MIPS?
- A physician (as defined in section 1861(r) of the Act)
- A physician assistant, nurse practitioner, or clinical nurse specialist (as such terms are defined in section 1861(aa)(5) of the Act)
- A certified registered nurse anesthetist (as defined in section 1861(bb)(2) of the Act)
- A physical therapist or occupational therapist
- A qualified speech-language pathologist
- A qualified audiologist (as defined in section 1861(ll)(3)(B) of the Act)
- A clinical psychologist (as defined by the Secretary for purposes of section 1861(ii) of the Act)
- A registered dietician or nutrition professional
- A group that includes such clinicians
2. What is a MIPS-eligible clinician?
A MIPS-eligible clinician is an eligible clinician described above who exceeds at least one of the three low-volume thresholds.
3. In 2019, what are the three low-volume thresholds?
In 2019, if an eligible clinician exceeds all of the following three low-volume thresholds, they will be required to participate in MIPS in 2019.
- You have more than $90,000 in Medicare Part B allowed charges
- You evaluated and/or treated more than 200 unique Medicare beneficiaries
- You provided more than 200 covered professional services under the Medicare Physician Fee Schedule.
4. How is the $90,000 in Medicare Part B allowed charges calculated?
For purposes of the low-volume threshold, Medicare Part B allowed charges is the Medicare allowed amount for each CPT code prior to the application of the multiple procedure payment reduction policy.
5. How is the more than 200 unique Medicare beneficiaries calculated?
For a physical therapist or occupational therapist in private practice, services are generally billed under your NPI number with payment reassigned to the practice. If you evaluate and/or treat more than 200 unique (different) Medicare beneficiaries during the determination period(s), you will exceed this low-volume threshold. Keep in mind that services provided by a physical therapist assistant or occupational therapy assistant in a private practice are billed under the NPI of the PT or OT who is providing the direct supervision. This means that one PT could evaluate a Medicare beneficiary and that would count as one unique Medicare beneficiary for that PT. That Medicare beneficiary now comes in for a follow up visit and is seen by a PTA. The PT who did the evaluation is not onsite that day, so the PTA is directly supervised by a different PT. Since the services of the PTA are billed under the NPI of the PT who is providing the direct supervision, this Medicare beneficiary would now count as a unique Medicare beneficiary for the second PT as well since they are providing direct supervision to the PTA.
6. How is the more than 200 covered professional services under the Medicare Physician Fee Schedule calculated?
Per the CMS final rule, “a clinician may identify and monitor a claim to distinguish covered professional services from Part B items and services by calculating one professional claim line with positive allowed charges to be considered one covered professional service”.
For example, if a clinician billed CPT code 97110 (therapeutic exercise) on one claim line for three units, this would count as one covered professional service. However if a clinician billed CPT code 97110 for three units as one unit on three different claim lines, this would count as three covered professional services.
7. What is the determination period that CMS will use to see if an eligible clinician will be required to participate in MIPS in 2019?
CMS will use two 12-month segments to determine if an eligible clinician will be required to participate in MIPS in 2019. The first segment begins October 1, 2017, and ends on September 30, 2018, and will include a 30-day claims run out. The second segment begins October 1, 2018, and ends September 30, 2019, and will not include a claims run out, but will instead include quarterly snapshots for informational use only, if technically feasible.
If an eligible clinician exceeds all three low-volume thresholds at the same practice during both determination periods, they will be required to participate in MIPS in 2019.
If an eligible clinician exceeds all three low-volume thresholds during the first determination period, stays in the same practice, and does not exceed all three low-volume thresholds during the second determination period, they will not be required to participate in MIPS in 2019.
If an eligible clinician does not exceed all three low-volume thresholds during the first determination period, leaves that practice, joins another private practice, and then exceed all three low-volume thresholds during the second determination period in their new private practice, they would be required to participate in MIPS in 2019.
8. If I’m not required to participate in MIPS in 2019, can I opt-in for the chance for a positive payment adjustment in 2021?
Yes! A physical therapist and/or occupational therapist in private practice can opt in to the MIPS program for performance year 2019 as long as they, as an individual (single NPI) or as a group (two or more NPIs under one TIN), exceed at least one of the three low-volume thresholds during the determination period(s).
9. What are the four performance categories in the MIPS program?
The four performance categories are as follows:
- Improvement activities
- Promoting interoperability
10. In 2019, how many quality measures must physical therapists, occupational therapists, and speech-language pathologists report?
In performance year 2019, MIPS-eligible clinicians or groups must report up to six quality measures, including one outcome measure, for the 12-month calendar year performance period with 60% completeness.
11. How is the 60% completeness defined?
The definition of 60% completeness depends on how you are submitting the quality measures to CMS:
- Claims Reporting – 60 % completeness is calculated on all of your Medicare Part B patients (traditional Medicare)
- Registry Reporting – 60 % completeness is calculated on all of your patients (Medicare and non-Medicare patients)
Registry reporting includes MIPS CQMs and QCDR.
Hopefully this provides you a decent introduction to MIPS!
To learn more, be sure to register for my upcoming free live webinar with MedBridge, “Navigating MIPS for Physical and Occupational Therapy in 2019” – register today!