Under the final Quality Payment Program (QPP) rule for 2019, the Centers for Medicare and Medicaid Services (CMS) announced that audiologists will be considered “eligible clinicians” for QPP participation, effective January 1, 2019. The QPP replaced the Sustainable Growth Rate (SGR) formula that for many years served as the underpinning of Medicare provider payment. 

The QPP will begin its third year in 2019. Until now, only physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists (or groups or virtual groups that include one of these clinicians) were included in the QPP. For 2019, CMS expanded the provider types included under QPP to audiologists, speech-language pathologists, physical therapists, occupational therapists, clinical psychologists, and registered dietitians or nutrition professionals.

There are two paths to participation under QPP: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (AAPM). MIPS will be the pathway most feasible for audiologists. MIPS includes the former Physician Quality Reporting System (PQRS) measures that audiologists reported to CMS.

Those required to report beginning January 1, 2019, will see payment adjustments effective January 1, 2021. Successful reporting under MIPS can result in a payment bonus up to 7 percent. Conversely, failure to meet reporting benchmarks may result in up to a 7 percent reduction in reimbursement. Eligible providers must submit data by March 31, 2020, to avoid a negative payment adjustment.

We estimate up to 99 percent of audiologists who are individual reporters will be excluded automatically from QPP participation. Check participation status with CMS at qpp.cms.gov/participation-lookup.

Required Participants

Clinicians must meet all of the following requirements to be required to report under QPP: 

  • Clinicians or groups that billed $90,000 or more in allowed charges under the Medicare Physician Fee Schedule (MPFS), furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare secondary payer)
  • Clinicians or groups that provide care to 200 or more Medicare Part B FFS beneficiaries
  • Clinicians or groups that provide more than 200 distinct procedures to Medicare Part B beneficiaries

Participants may submit data as an individual or as part of a group. Individual clinicians are identified by a unique combination of individual National Provider ID (NPI) and Tax ID Number (TIN). Clinicians who assigned their Medicare billing rights to a group organizational TIN can submit data as part of a group or as an individual.

Low-Volume Threshold Exclusion

Most audiologists will meet at least one of the following low-volume criteria and be excluded automatically from MIPS participation in 2019:

  • Have $90,000 or less in Part B allowed charges for covered professional services; 
  • Provide care to 200 or fewer Part B enrolled beneficiaries; or
  • Provide 200 or fewer covered professional services under the MPFS.

Voluntary Reporting and Opt-In Option

Audiologists may choose to voluntarily report under MIPS. CMS also offers an “opt-in” option, distinct from voluntary reporting. Providers who meet one or more criteria for the low-volume exception may “opt-in” to MIPS. If a provider elects to participate, however, status cannot change for the performance period. The provider will be subject to performance-based payment adjustments, either positive or negative, in 2021. 

Data Submission Mechanisms 

There are multiple submission mechanisms for MIPS reporting: 

  • Qualified Clinical Data Registry (QCDR)
  • 2015 Edition Certified Electronic health record (EHR)
  • Qualifying registry
  • Claims
  • CMS web interface
  • Attestation

MIPS Performance Categories

Four performance categories are part of a provider’s final score, which determines the payment adjustment. For audiologists, 2019 reporting will be limited to the Quality and Clinical Improvement categories.

Quality

This category replaces PQRS. Providers must report on six quality measures for successful reporting: 

  • Measure #130—Documentation of Current Medications in the Medical Record
  • Measure # 134—Screening for Clinical Depression and Follow-up Plan
  • Measure # 154—Falls: Risk Assessment
  • Measure # 155—Falls: Plan of Care
  • Measure # 226—Preventative Care and Screening: Tobacco Use—Screening and Cessation Intervention
  • Measure # 261—Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

Promoting Interoperability

CMS renamed the Advancing Care Information performance category to Promoting Interoperability (PI). This replaced the Medicare EHR Incentive Program (Meaningful Use). Audiologists are exempt from this category.

Improvement Activities

This category includes an inventory of activities that assess how providers improve care processes, patient engagement, and access to care. For the inventory of ongoing eligible activities from 2017 and 2018, see qpp.cms.gov/mips/improvement-activities. For 2019, CMS approved six additional activities, but most are not related to audiology practice. 

Improvement activities may be submitted to CMS through registries, some EHRs, and the CMS QPP Portal. 

Cost

The cost of care provided will be calculated by CMS based on Medicare claims. Audiologists are exempt from this category.

Resources 

CMS offers resources on MIPS participation. See QPP.CMS.gov. 

The Academy will post updated QPP information on www.audiology.org.