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2021 Medicare Physician Fee Schedule Quality Payment Program Summary: Radiology

September 4, 2020

On August 3, 2020, the Centers for Medicare and Medicaid Services (CMS) released its CY 2021 Medicare Physician Fee Schedule (PFS) proposed rule, which includes changes to Medicare Part B payment and other policies, as well the Quality Payment Program (QPP).
CMS is not proposing any significant changes to the QPP due to the Public Health Emergency (PHE) still in effect. The following is a summary of the significant provisions contained in the QPP portion of the Proposed Rule:

2020 MIPS Provisions
Policies that would Impact the 2020 Reporting Year:

  • For 2020 only, CMS is doubling the complex patient bonus from five points to a maximum of ten points added to the overall MIPS performance score to account for additional complexities due to the COVID-19 pandemic.
  • CMS established a 2020 hardship exception policy due to the COVID-19 pandemic, which allows physicians and groups to either (1) opt-out of MIPS completely and be held harmless from a penalty, or (2) opt-out of any of the individual MIPS categories. This is not a proposal, but rather an official self-executing administrative policy.
  • For performance year 2020, all ACOs are considered to be affected by the PHE and the MSSP extreme and uncontrollable circumstances policy applies.

2021 Quality Payment Program Proposals
MIPS Value Pathways
In the 2020 PFS, CMS finalized the concept of MIPS Value Pathways (MVP) with the intention of beginning to introduce MVPs in the 2021 PFS. MVPs are templates for how to participate in MIPS. CMS is not introducing any MVPs in the 2021 PFS and they will not be available for reporting until CY 2022 or later.

Proposed MIPS Performance Thresholds and Category Weights
Performance Thresholds:

  • Performance Threshold to avoid a penalty, of up to -9%, and attain a 0% Payment Adjustment: 50 points (up from 45 points in 2020).
  • Exceptional Performance Threshold remains at 85 points (same as 2020) to be eligible for the$500 million pool.

2021 Category Weights:

  • Quality: 40% (5% decrease from PY 2020)
  • Cost: 20% (5% increase from PY 2020)
  • PI: 25% (no change from PY 2020)
    • For Non-patient Facing Groups (NPF) the PI category will again be reweighted to Quality.
  • IA: 15% (no change from PY 2020)

By law, the Cost and Quality performance categories must become equally weighted at 30% by the 2022 performance period.

2021 Performance Period Scoring:

  • Due to the PHE, 2021 performance period benchmarks will be used to score Quality Measures. CMS is concerned that there will not be a representative sample of historic data from 2019, which could skew benchmarks.
    • Typically, CMS uses historical benchmarks to score quality measures based on performance data gathered two years before the performance year.
    • This means that groups will not be able to review measure benchmarks in advance of reporting them.
  • Since CMS is proposing to use performance period benchmarks for 2021, not historical benchmarks, the scoring policy for topped-out measures must be updated.
    • The seven measure achievement point cap will be applied only if the measure is identified as topped out, based on the established benchmarks for both the 2020 and 2021 performance periods.
    • Existing measure specifications will be updated to include telehealth services that are directly applicable to existing episode-based cost measures and the TPCC measure.

Quality Performance Category
CMS is proposing a total of 206 Quality Measures for the 2021 performance period. This includes substantive changes to 112 existing MIPS Quality Measures and removal of 14 Quality Measures.

  • Measure 146 has been proposed for removal from the Diagnostic Radiology Measure Set.
  • Individual Measure Denominator and/or Numerator clarifications or changes are proposed for the following Radiology Measures:
    • 145, 147 195, 364, 405 and 374 (from the IR Measure Set)

As noted above, the weight of the Quality category is proposed to decrease over time to 30% by 2022. However, even as the Quality category weight is reduced, it is important to note, as most radiology groups are “Non-patient Facing,” the Promoting Interoperability category is being reweighted to “Quality”; meaning, Quality is still the most significant component in overall scoring.

Cost Category

  • The Cost Category is updated to existing measure specifications.
  • This includes telehealth services that are directly applicable to existing episode-based cost measures and the TPCC measure.

Improvement Activity Category

  • Must modify two existing activities.
  • Expand criteria for creating a new improvement activity to include those activities that can be linked to existing and related MIPS quality and cost measures.

APM Performance Pathway (APP)
CMS proposes a new APM Performance Pathway (APP) in 2021. This new Pathway would be complementary to MVPs. The APP would be available only to participants in MIPS APMs and may be reported by the individual eligible clinician, group (TIN), or APM Entity.

  • In the APP, Cost would be weighted at 0%; IA would automatically get full credit; PI would be reported and scored at the individual or group level, as is required for the rest of MIPS.
  • Quality will be composed of six measures that are specifically focused on population health and widely available to all MIPS APM participants.

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