Title 42
SECTION 414.1370
414.1370 APM scoring standard under MIPS.
§ 414.1370 APM scoring standard under MIPS.(a) General. For the 2019 through 2022 MIPS payment years, the APM scoring standard is the MIPS scoring methodology applicable for MIPS eligible clinicians identified on the Participation List for the performance period of an APM Entity participating in a MIPS APM.
(b) Criteria for MIPS APMs. MIPS APMs are those in which:
(1) APM Entities participate in the APM under an agreement with CMS or through a law or regulation;
(2) The APM is designed such that APM Entities participating in the APM include at least one MIPS eligible clinician on a Participation List;
(3) The APM bases payment on quality measures and cost/utilization; and
(4) The APM is not either of the following:
(i) New APMs. An APM for which the first performance year begins after the first day of the MIPS performance period for the year.
(ii) APM in final year of operation for which the APM scoring standard is impracticable. An APM in the final year of operation for which CMS determines, within 60 days after the beginning of the MIPS performance period for the year, that it is impracticable for APM Entity groups to report to MIPS using the APM scoring standard.
(c) APM scoring standard performance period. The MIPS performance period under § 414.1320 applies for the APM scoring standard.
(d) APM participant identifier. The APM participant identifier for an eligible clinician is the combination of four identifiers:
(1) APM identifier (established for the APM by CMS);
(2) APM Entity identifier (established for the APM Entity by CMS);
(3) Medicare-enrolled billing TIN; and
(4) Eligible clinician NPI.
(e) APM Entity group determination. For the APM scoring standard, the APM Entity group is determined in the manner prescribed in § 414.1425(b)(1).
(1) Full TIN APM. In addition to the dates set forth in § 414.1425(b)(1), the APM Entity group includes an eligible clinician who is on a Participation List in a Full TIN APM on December 31 of the MIPS performance period.
(2) For purposes of calculating the APM Entity group score under the APM scoring standard, MIPS scores submitted by virtual groups will not be included.
(f) APM Entity group scoring under the APM scoring standard. The MIPS final score calculated for the APM Entity is applied to each MIPS eligible clinician in the APM Entity group. The MIPS payment adjustment is applied at the TIN/NPI level for each of the MIPS eligible clinicians in the APM Entity group.
(1) If a Shared Savings Program ACO does not report data on quality measures as required by the Shared Savings Program under § 425.508 of this chapter, each ACO participant TIN will be treated as a unique APM Entity for purposes of the APM scoring standard and the ACO participant TINs may report data for the MIPS quality performance category according to the MIPS submission and reporting requirements.
(2) MIPS eligible clinicians who participate in a group or have elected to participate in a virtual group and who are also on a MIPS APM Participation List will be included in the assessment under MIPS for purposes of producing a group or virtual group score and under the APM scoring standard for purposes of producing an APM Entity score. The MIPS payment adjustment for these eligible clinicians is based solely on their APM Entity score; if the APM Entity group is exempt from MIPS all eligible clinicians within that APM Entity group are also exempt from MIPS.
(g) MIPS performance category scoring under the APM scoring standard - (1) Quality. Beginning in the 2020 Performance year -
(i) MIPS APMs that require APM Entities to submit quality data through a MIPS submission mechanism. The MIPS quality performance category score for a performance period will be calculated for the APM Entity using the data submitted for the APM Entity through a MIPS submission mechanism in accordance with § 414.1335.
(ii) MIPS APMs that do not require APM Entities to submit quality data through a MIPS submission mechanism. The APM Entity will be assigned an APM Quality Reporting Credit worth 50 percent of the total quality performance category score. The APM Quality Reporting Credit will be added to the MIPS quality performance category score to generate an APM Entity quality performance category score, which in no case shall exceed 100. The MIPS quality performance category score for a performance period will be calculated for the APM Entity using the data submitted for the APM Entity through a MIPS submission mechanism in accordance with § 414.1335.
(iii) Determination of score for each MIPS eligible clinician in an APM entity. Regardless of whether a MIPS APM requires APM Entities to submit quality data through a MIPS submission mechanism, if data are not submitted for an APM Entity through a MIPS submission mechanism in accordance with § 414.1335, the score for each MIPS eligible clinician in such APM Entity is the higher of either:
(A) A TIN level score based on the measure data for the quality performance category reported by a TIN for the MIPS eligible clinician in accordance with § 414.1335; or
(B) An individual level score based on the measure data for the quality performance category reported by the MIPS eligible clinician in accordance with § 414.1335.
(iv) Quality improvement score. For an APM Entity for which CMS calculated a total quality performance category score for one or more participants in the APM Entity for the preceding MIPS performance period, CMS calculates a quality improvement score for the APM Entity group as specified in § 414.1380(b)(1)(xvi).
(2) Cost. The cost performance category weight is zero percent for APM Entities in MIPS APMs.
(3) Improvement activities. (i) CMS assigns an improvement activities score for each MIPS APM for a MIPS performance period based on the requirements of the MIPS APM. The assigned improvement activities score applies to each APM Entity group for the MIPS performance period. In the event that the assigned score does not represent the maximum improvement activities score, an APM Entity may report additional activities.
(ii) [Reserved]
(4) Promoting Interoperability. (i) For the 2019 and 2020 MIPS payment years, each Shared Savings Program ACO participant TIN must report data on the Promoting Interoperability performance category separately from the ACO, as specified in § 414.1375(b)(2). The ACO participant TIN scores are weighted according to the number of MIPS eligible clinicians in each TIN as a proportion of the total number of MIPS eligible clinicians in the APM Entity group, and then aggregated to determine an APM Entity score for the ACI performance category.
(ii) For the 2019 and 2020 MIPS payment years, for APM Entities in MIPS APMs other than the Shared Savings Program, CMS uses one score for each MIPS eligible clinician in the APM Entity group to derive a single average APM Entity score for the Promoting Interoperability performance category. Beginning with the 2021 MIPS payment year, for APM Entities in MIPS APMs including the Shared Savings Program, CMS uses one score for each MIPS eligible clinician in the APM Entity group to derive a single average APM Entity score for the Promoting Interoperability performance category. The score for each MIPS eligible clinician is the higher of either:
(A) A group score based on the measure data for the Promoting Interoperability performance category reported by a TIN for the MIPS eligible clinician according to MIPS submission and reporting requirements for groups; or
(B) An individual score based on the measure data for the Promoting Interoperability performance category reported by the MIPS eligible clinician according to MIPS submission and reporting requirements for individuals.
(iii) In the event that a MIPS eligible clinician participating in a MIPS APM receives an exception from the Promoting Interoperability performance category reporting requirements, such eligible clinician will be assigned a null score when CMS calculates the APM Entity's Promoting Interoperability performance category score under the APM scoring standard.
(A) If all MIPS eligible clinicians in an APM Entity have been excepted from reporting the Promoting Interoperability performance category, the performance category weight will be reweighted to zero for the APM Entity for that MIPS performance period.
(B) [Reserved]
(h) APM scoring standard performance category weights. The performance category weights used to calculate the MIPS final score for an APM Entity group for the APM scoring standard performance period are:
(1) Quality. (i) For MIPS APMs that require use of the CMS Web Interface: 50 percent.
(ii) For Other MIPS APMs, 0 percent for 2017, 50 percent beginning in 2018.
(2) Cost. 0 percent.
(3) Improvement activities. (i) For MIPS APMs that require use of the CMS Web Interface: 20 percent.
(ii) For Other MIPS APMs, 25 percent for 2017, 20 percent beginning in 2018.
(4) Promoting Interoperability. (i) For MIPS APMs that require use of the CMS Web Interface: 30 percent.
(ii) For Other MIPS APMs, 25 percent for 2017, 30 percent beginning in 2018.
(5) Reweighting the MIPS Performance categories for the APM scoring standard. If CMS determines there are not sufficient measures or activities applicable and available to MIPS eligible clinicians, CMS will assign weights as follows:
(i) If CMS reweights the quality performance category to 0 percent:
(A) In 2017, the improvement activities performance category is reweighted to 25 percent and the Promoting Interoperability performance category is reweighted to 75 percent; and
(B) Beginning in 2018, the Promoting Interoperability performance category is reweighted to 75 percent and the improvement activities performance category is reweighted to 25 percent.
(ii) If CMS reweights the Promoting Interoperability performance category to zero percent:
(A) In 2017, the quality performance category is reweighted to 75 percent and the improvement activities performance category will remain at 25 percent.
(B) Beginning in 2018, the quality performance category is reweighted to 80 percent and the improvement activities performance category will remain at 20 percent.
(i) Total APM Entity Score. CMS scores each performance category and then multiplies each performance category score by the applicable performance category weight. CMS then calculates the sum of each weighted performance category score and then applies all applicable adjustments. APM Entities will receive MIPS bonuses applied to the final score as set forth in § 414.1380(b).
[81 FR 77537, Nov. 4, 2016, as amended at 82 FR 53953, Nov. 16, 2017; 83 FR 23610, May 22, 2018; 83 FR 60080, Nov. 23, 2018; 84 FR 63196, Nov. 15, 2019; 85 FR 85031, Dec. 28, 2020]