Quality Payment Program

The AAOS Quality Payment Program (QPP) Information Center offers tools and resources to help you and your practice prepare for and navigate through either of the two QPP tracks - The Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). For the most recent advocacy news, comment/congressional letters, and current AAOS position statements, see the "Advocacy" tab above. Have additional questions about the QPP? Questions can be submitted directly to CMS via email at QPP@cms.hhs.gov or (866) 288-8292.

The QPP includes two tracks: the Merit-based Incentive Payment System (MIPS) track and the Advanced Alternative Payment Models (APMs) track. You can choose how you want to participate based on your practice size, specialty, location, or patient population.

You're a part of the Quality Payment Program in 2021 if you are in an Advanced APM or if you have more than $90,000 in Part B allowed charges for covered professional services, provide care to more than 200 beneficiaries, and provide more than 200 covered professional services under the PFS. You must meet all three aspects of the low-volume threshold (i.e. minimum billing, number of patients, and covered services) to be in the program. If you are below any of the low-volume threshold criteria, you are not in the program. You can check participation status for your NPI using the QPP Participation Look Up Tool.

You can check participation status for your NPI using the QPP Participation Look Up Tool.

1. Merit-based Incentive Payment System (MIPS) combines previous Medicare reporting requirements (i.e. Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-based Payment Modified (VPM)) into a single program that ties fee-for-service payment to performance. Physicians will receive payment adjustments based on Quality, Promoting Interoperability, Clinical Improvement Activities, and Cost (resource use).
   
   
2. Advanced Alternative Payment Models (APMs) is a payment approach that lets practices earn more for taking on some risk related to patients' outcomes. You may earn 5% Medicare incentive payment during 2019 through 2024 and be exempt from MIPS reporting requirements and payment adjustments if you have sufficient participation in an Advanced APMs.

2021 Program Year

MIPS will be the pathway for a majority of Orthopaedic Surgeons to participate in QPP. MIPS combines CMS's three previous reporting programs - Physician Quality Reporting System (PQRS), Value-based Modifier, and EHR Meaningful Use, under a single entity. Performance Year 2021 is Year 5 of the program.

Orthopaedic surgeons may choose to participate in MIPS as:

• An individual
• A group
• A virtual group
• An APM Entity

2021 MIPS Metrics

To calculate your MIPS score, CMS will evaluate your performance in four categories. Scores in each area will be weighted. CMS adjusts the weights for each category each program year. By Performance Year 2022, both Quality and Cost must be equally weighted at 30% each.

1. Quality - 40%
   • Must submit data for at least 6 measures (or a complete specialty measure set) while one of these measures should be an outcome measure (if you have no applicable outcome measure, may submit another high priority measure instead).
   • Must report on at least 70% of patients who qualify for each measure for Year 5 (i.e. data completeness requirement).
   • In Year 5, eligible clinicians can collect quality measure data via MIPS CQM, eCQM, QCDR measures, and for small practices, Medicare Part B claims measures.
   • There are four submission types for quality measure data: sign in & upload, CMS web Interface, direct submission via Application Programming Interface (API), and Medicare Part B claims.
   • Bonus points are awarded for reporting more than one outcome or high priority measure and/or using certified EHR technology (CEHRT) to collect measure data and meet end-to-end electronic reporting.
   • For small practices, 6 bonus points are added to the numerator of the Quality performance category for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure.
   • There are 2 new administrative claims quality measures that will be automatically evaluated and calculated, if the following case minimum requirements are met:
     • Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Eligible Clinicians Groups
       • 200 case minimum
       • 1-year measurement period
       • Only applies to groups, and virtual groups, and APM Entities with 16 or more clinicians and that meet the case minimum
     • Risk-standardized Complication Rate (RSCR) Following Electric Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for Merit-Based Incentive Payment System (MIPS)
       • 25 case minimum
       • 3-year measurement period
       • Applies to individual clinicians, groups and virtual groups that meet the case minimum
2. Promoting Interoperability (PI) - 25%
   • Promoting Interoperability measures remain largely unchanged for Year 5, except:
     • The Query of Prescription Drug Monitoring Program (PDMP) measure will remain as an optional measure worth 10 bonus points.
     • The name of the Support Electronic Referral Loops by Receiving and Incorporating Health Information will be changed to Support Electronic Referral Loops by Receiving and Reconciling Health Information.
     • Addition of an optional Health Information Exchange (HIE) bi-directional exchange measure as an alternative reporting option to the 2 existing measures for the HIE objective.
   • Must collect data for all required measures (unless you can claim an exclusion(s)) for the same minimum continuous 90-day period in CY 2021.
   • The scores for each of the individual measures will be added together to calculate the score of up to 100 possible points. If exclusions are claimed, the points for measures will be reallocated to other measures.
   • Eligible clinicians must use technology certified to the existing 2015 Edition certification criteria, technology certified to the 2015 Edition Cures Update certification criteria, or a combination of both.
3. Clinical Improvement Activities (CPIA) - 15%
   • Category that focuses on care coordination, beneficiary engagement, and patient safety.
   • To earn full credit (40 points) in this performance category, you must generally submit one of the following combinations of activities:
     • 2 high-weighted activities,
     • 1 high-weighted activity and 2 medium-weighted activities, or
     • 4 medium-weighted activities
   • Improvement activities have a continuous 90-day performance period (during calendar year (CY) 2021) unless otherwise stated in the activity description.
   • List of orthopaedic-related improvement activities - In development
4. Cost - 20%
   • No data submission is required for the cost category. CMS will calculate your score based on claims data in 2021 and report it to you via feedback report.
   • There are 20 cost measures available for Year 5. There are no new cost measures available in the 2021 MIPS PY. The cost performance category will be reweighted to 0% for MIPS APM Entities that choose to report to traditional MIPS and report both quality and improvement activity data.

For scoring Facility-Based Quality and Cost Performance Categories, all the following conditions must be met:

• You’re identified as facility-based.
• You’re attributed to a facility with a FY 2022 Hospital Value-Based Purchasing (VBP) Program score.
• The Hospital VBP Program score results in a higher combined quality and cost score than the MIPS quality measure data you submit and MIPS cost measure data CMS calculates for you.

Scoring: A single MIPS composite performance score will factor in performance in the four weighted categories. Orthopaedic Surgeons can receive positive or negative payment adjustments based on their composite performance score. There will be "winners" and "losers".

To avoid a negative payment adjustment for the 2021 Performance Year (2023 Payment Year), participants must achieve a composite score of at least 60 points. Exceptional performers, those who achieve a composite score of 85 points or more, are eligible to receive an additional positive payment adjustment.

Advanced APMs are the second track for QPP compliance, though it may be the less popular pathway for Orthopaedic Surgeons. This option lets practices earn more for taking on some risk related to their patients' outcomes. If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model.

Advanced APMs are APMs that meet the following 3 criteria:

• Requires participants to use certified EHR technology;
  • At least 75% of eligible clinicians in each APM Entity must use CEHRT to document and communicate clinical care with patients and other health care professionals.
• Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
• Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a significant financial risk.

Qualifying APM Participants (QPs) are eligible for the 5 percent incentive payment and excluded from the MIPS reporting requirement. To be considered a QP, you must receive at least 50 percent of your Medicare Part B payments or see at least 35 percent of Medicare patients through an Advanced APM entity during the QP performance period (January 1 - August 31).

Partial Qualifying APM Participants (Partial QPs) can choose whether they want to participate in MIPS. To be considered a Partial QP, you must receive at least 40 percent of your Medicare Part B payments or see at least 25 percent of Medicare patients through an Advanced APM entity during the QP performance period (January 1 - August 31). If a Partial QP chooses to not report MIPS, they will receive no payment adjustment.

BPCI-Advanced is an example of an Advanced APM, through which orthopaedic surgeons may be participating.

View a list of approved Advanced APMs (last updated November 2020)

New for Performance Year 2021 – The APM Performance Pathway (APP)

• APP reporting is available only to MIPS eligible clinicians participating in APMs and it is required for Medicare Shared Savings Program ACOs.
• The APP Core Quality Measure set is predetermined by CMS and required for those participating in the APP. It consists of the following measures for Performance Year 2021:
  • For the 2021 performance period only, participants in ACOs have the option to report the 10 CMS Web Interface measures in place of these 3 eCQMs/MIPSCQMs in the APP.
  • *Note: CMS Web Interface to sunset after PY 2021.
• Cost will be weighted at 0% because APMs already share risk and the PI measures will remain the same because they are statutorily required.
• The improvement activities will be whatever the MIPS APM requires and as a first-year incentive, all APP participants will get a score of 100% on the IA category.

MIPS Value Pathways (MVPs) Delayed until Performance Year 2022

In the CY 2021 Medicare Physician Fee Schedule Final Rule, CMS decided to delay implementation of its new MVP reporting pathway until January 1, 2022.

In its early stages (first 1-2 years), CMS envisions the MVP framework aligning relevant, meaningful quality, improvement activity, and cost measures. These measures build upon a foundation of the statutorily required Promoting Interoperability measures and administrative claims-based Population Health Measures. In future years, they hope to incorporate more administrative claims measures and enhance their performance feedback capabilities.

Advanced APMs will be the less chosen pathway for Orthopaedic Surgeons in 2017. This option lets practices earn more for taking on some risk related to their patients' outcomes. If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model. 

The 2019 Quality Payment Program rule changes amended the Advanced APM quality criteria to state that at least one of the quality measures upon which an Advanced APM bases payment must be:  

• On the MIPS final list,
• Endorsed by a consensus-based entity, or 
• Otherwise determined by CMS to be evidence-based, reliable, and valid. This provision applies beginning in 2020

CMS also increased the CEHRT use threshold for Advanced APMs so that an Advanced APM must require at least 75% of eligible clinicians in each APM Entity use CEHRT to document and communicate clinical care with patients and other health care professionals. 

View a list of approved Advanced APMs