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For the 2021 performance year, the Cost category makes up 20 percent of the MIPS final score, up from 15 percent in 2020. CMS calculates performance under this category automatically using claims data, which means that no reporting is required to comply with this category. Clinicians and groups may be assessed on any of the following cost measures if attributed a sufficient number of beneficiaries under each measure: 

  • Total per Capita Cost (TPCC) measure
  • Medicare Spending per Beneficiary (MSPB) measure
  • 18 episode-based cost measures that focus on specific conditions, including STEMI with PCI, and specific procedures, including Elective Outpatient PCI and Non-Emergent Coronary Artery Bypass Graft (CABG) 

CMS recently made revisions to the TPCC measure attribution methodology that limit its applicability to surgeons. However, surgeons still may be attributed surgical episodes under the newly revised MSPB measure, which assesses total Medicare Part A and B costs related to the care provided to a beneficiary during an episode defined as 3 days prior to a hospital admission (known as the “index admission”) through 30 days after hospital discharge. A surgical episode is attributed to the surgeon(s) who performed any related surgical procedure during the inpatient stay (i.e. identified through surgical MS-DRGs), as well as to the TIN under which the surgeon(s) billed for the procedure. A surgeon (or TIN) must be attributed at least 35 patients under the MSPB measure to be scored on it.   

For the more specific episode-based cost measures, CMS will use the following attribution methodologies: 

  • For acute inpatient medical condition episode-based measures, such as the STEMI with PCI measure: Episodes are attributed to each MIPS eligible clinician who bills inpatient E/M claim lines during the trigger inpatient hospitalization under a TIN that renders at least 30 percent of the inpatient E/M claim lines during that hospitalization. A clinician or group must be attributed at least 20 episodes to be scored on this type of measure.
  • For procedural episode-based measures, such as the Elective Outpatient PCI measure and the Non-Emergent CABG measure: Episodes are attributed to each MIPS eligible clinician who renders a trigger service as identified by specific HCPCS/CPT procedure codes. A clinician or group must be attributed a minimum of 10 episodes to be scored on this type of measure.

Depending on practice patterns, a clinician could be held accountable for multiple cost measures. CMS will assign 1 to 10 achievement points to each scored measure based on the individual’s or group’s performance compared to a national benchmark based on 2021 performance (not a historic benchmark). If a clinician or group is scored on multiple measures, each measure will contribute equally to the clinician’s or group’s total MIPS Cost category score. If only one measure can be scored, that measure’s score will serve as the Cost category score. If the clinician or group does not meet the minimum number of attributable patients for any of these measures, the clinician or group will not be held accountable for cost performance, and the entire weight of the Cost category (20 percent for 2021) will be redistributed to another category – most likely the Quality performance category.  

Additional information about the Cost category of MIPS, including 2021 cost measure specifications, is available on the QPP Cost Category webpage, as well as through the QPP Resource Library

Last updated: 5/28/2021