Cost

MIPS Performance Category

The Cost performance category replaced the Value-Based Modifier (VBM). The cost of the care provided is calculated by CMS, based on the clincian’s Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. As of 2018, this performance category counts toward the final MIPS score.

Scroll down to view a summary of the Cost performance category, as well as all 10 Cost Measures for 2019.

Or click a tab below to learn more about MIPS or any of the other three Performance Categories.


Cost: 2019 Key Facts


15%


For 2019, the Cost category makes up 15% of a provider’s final score. That’s up 5% from 2018.

Data Submission


Providers are evaluated, in the Cost category, based on their Medicare claims data. Thus, there are no data submission or reporting requirements.

Scoring


Providers are scored by comparing their performance against annual benchmarks, created by CMS. For 2019, cost measures are used to assess the beneficiary’s total cost of care during the year, or during a hospital stay, and/or 8 episodes of care.

Browse the Full List of 2019 Cost Measures

There are 10 Cost Measures for the 2019 MIPS Performance Year. All MIPS-eligible providers will be evaluated based on these measures. Explore all ten below, listed in alphabetical order.

Elective Outpatient Percutaneous Coronary Intervention (PCI)

The Elective Outpatient PCI cost measure is meant to apply to clinicians who perform Elective Outpatient PCIs for Medicare beneficiaries during the performance period. This surgical procedure is meant to place a coronary artery stent for heart disease in a non-emergent, outpatient setting. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_EOPCI_1

Submission Method

Administrative Claims

Intracranial Hemorrhage or Cerebral Infarction

The Intracranial Hemorrhage or Cerebral Infarction cost measure is meant to apply to clinicians who manage the inpatient care of Medicare beneficiaries hospitalized for an intracranial hemorrhage or cerebral infarction during the performance period. This cost measure excludes those patients whose initial hospitalization was due to a subarachnoid hemorrhage or a cerebral infarction which received thrombolytic therapy. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_IHCI_1

Submission Method

Administrative Claims

Knee Arthroplasty

The Knee Arthroplasty cost measure is meant to apply to clinicians who perform elective total and partial knee arthroplasties during the performance period for Medicare beneficiaries. This surgical procedure is meant to replace a patient’s own poorly functional knee with an artificial one, thereby reducing pain and increasing mobility. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_KA_1

Submission Method

Administrative Claims

Medicare Spending Per Beneficiary (MSPB)

The Medicare Spending Per Beneficiary (MSPB) measure evaluates solo practitioners and groups on their spending efficiency and is risk-adjusted to account for patients’ risk profiles. Solo practitioners and groups are identified by their National Provider Identification (NPI) and Taxpayer Identification Number (TIN) combination. Specifically, the MSPB measure assesses the average spend for Medicare services performed by providers/groups per episode of care. Each episode comprises the period immediately prior to, during, and following a patient’s hospital stay.

Measure ID

MSPB_1

Submission Method

Administrative Claims

Revascularization for Lower Extremity Chronic Critical Limb Ischemia

The Revascularization for Lower Extremity Chronic Critical Limb Ischemia cost measure is meant to apply to clinicians who perform elective revascularization for lower extremity chronic critical limb ischemia for Medicare beneficiaries during the performance period. This surgical procedure is meant to alleviate symptoms of pain and difficulty walking associated with chronic limb ischemia and excludes those patients who require emergent revascularization for acute limb ischemia. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_CCLI_1

Submission Method

Administrative Claims

Routine Cataract Removal with Intraocular Lens (IOL) Implantation

The Routine Cataract Removal with IOL Implantation cost measure is meant to apply to clinicians who perform Routine Cataract Removal with IOL Implantation procedures for Medicare beneficiaries during the performance period. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_IOL_1

Submission Method

Administrative Claims

Screening/Surveillance Colonoscopy

The Screening/Surveillance Colonoscopy cost measure is meant to apply to clinicians who perform screening/surveillance colonoscopy procedures for Medicare beneficiaries during the performance period. Screening and surveillance colonoscopies are preventative care procedures that are meant to detect the presence of colorectal cancer (CRC) among patients who are at average risk or high risk of CRC, respectively. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_SSC_1

Submission Method

Administrative Claims

Simple Pneumonia with Hospitalization

The Simple Pneumonia with Hospitalization cost measure is meant to apply to clinicians who manage the inpatient care of Medicare beneficiaries hospitalized with simple pneumonia during the performance period. This acute inpatient medical condition episode group is meant to capture patients who are hospitalized for pneumonia without severe complicating factors. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_SPH_1

Submission Method

Administrative Claims

ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)

The STEMI with PCI cost measure is meant to apply to clinicians who manage the inpatient care of Medicare beneficiaries hospitalized during the performance period for a STEMI requiring PCI. This acute medical condition captures the care of those patients who present with STEMI indicating complete blockage of a coronary artery who emergently receive PCI as treatment. The measure evaluates a clinician’s risk-adjusted cost for the episode group by averaging it across all episodes attributed to the clinician. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other health care providers over the length of the episode, or “episode window.” The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the performance period.

Measure ID

COST_STEMI_1

Submission Method

Administrative Claims

Total Per Capita Costs (TPCC)

The Total Per Capita Costs (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN).

Measure ID

TPCC_1

Submission Method

Administrative Claims

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