November 1, 2024

Medical Coding What is MIPS & AAPM

AAPC | Certification | HCC Internship | Medical Coding | Medical Coding Grants | Medical Coding Scholarships | Online Medical Coding Training | Uncategorized
By Janine Mothershed

Understanding MIPS & AAPM in Medical Coding

The Merit-Based Incentive Payment System (MIPS) is a critical component of the Quality Payment Program (QPP) designed to improve healthcare quality while managing costs. As healthcare providers transition to value-based care, understanding MIPS guidelines is essential for medical coders, as these guidelines impact reimbursement and overall practice performance. Here’s an overview of MIPS, its components, and the role of medical coding in compliance.

Advanced Alternative Payment Models (AAPMs) and the Merit-based Incentive Payment System (MIPS) are both tracks in the Quality Payment Program (QPP):

  • AAPMs

    A select group of APMs that meet advanced requirements for quality, risk, and technology. Clinicians who participate in AAPMs are eligible for incentives and are excluded from MIPS. 

  • MIPS

    A track in the QPP that clinicians can choose to participate in. MIPS data has a two-year delay, so payments in 2024 are based on MIPS scores from 2022. 

    Here are some details about AAPMs and MIPS: 

AAPM incentives

Clinicians who meet participation thresholds for AAPMs become Qualifying APM Participants (QPs). QPs receive incentives, including: 

  • Exclusion from MIPS reporting and payment adjustments 
  • APM Incentive Payments 
  • Increased physician fee schedule updates 
  • MIPS participation

    Clinicians who don’t earn QP or Partial QP status may be required to participate in MIPS. 

  • APM scoring

    Clinicians who participate in APMs that don’t qualify as AAPMs may receive special scoring under MIPS. 

  • APM design
    The American Medical Association (AMA) believes that well-designed APMs can improve patient care and outcomes, while also lowering health care spending. The AMA also emphasizes that physicians should be involved in the design of APMs

    Advanced Alternative Payment Models (AAPMs) area type of payment model that incentivizes physicians to provide high-quality, cost-effective care: 

    • What they are

      AAPMs are one of the tracks in the Quality Payment Program (QPP). They are a subset of Alternative Payment Models (APMs), which are payment approaches that encourage high-quality and cost-efficient care. 

    • How they work

      AAPMs offer incentives to physicians who meet participation thresholds based on their levels of payments or patients. Physicians who achieve these thresholds become Qualifying APM Participants (QPs). 

    • What they require

      AAPMs require participants to: 

      • Use certified electronic health record (EHR) technology 
      • Provide payment for covered professional services based on quality measures 
    • What they offer

      QPs receive certain incentives, including: 

      • A higher Physician Fee Schedule update for performance years 2024 and beyond 
      • A 5% bonus 
    • What they exclude
      QPs are excluded from participating in the Merit-based Incentive Payment System (MIPS) trac

What is MIPS?

MIPS consolidates several existing quality programs into a single framework, incentivizing healthcare providers to deliver high-quality services. Providers are scored based on four performance categories:

  1. Quality: This category replaces the Physician Quality Reporting System (PQRS). Providers report on various quality measures that reflect their practice. A higher score here can lead to better reimbursement rates.
  2. Cost: This category evaluates the cost of care provided to patients. It measures the overall expenses associated with episodes of care, helping to identify more efficient practices.
  3. Improvement Activities: Providers can earn points by engaging in activities aimed at improving clinical practice, such as implementing evidence-based guidelines or engaging in care coordination.
  4. Promoting Interoperability: This category focuses on the use of certified electronic health record (EHR) technology to improve patient care through data sharing and communication.

Key Guidelines for Medical Coders

As medical coders, understanding MIPS guidelines is crucial for accurate reporting and compliance.

Here are some essential aspects to consider:

  1. Measure Selection: Coders must be familiar with the specific quality measures relevant to the provider’s specialty. This involves accurate coding of services provided to ensure that they align with the selected measures.
  2. Documentation Accuracy: Thorough and precise documentation is vital. Coders should ensure that all clinical information is recorded accurately to support the claims for quality measures and activities. This includes patient history, treatment plans, and outcomes.
  3. Code Updates: MIPS guidelines and associated codes can change annually. Coders should stay updated on these changes, including ICD-10, CPT, and HCPCS codes, to maintain compliance and avoid penalties.
  4. Data Submission: Coders play a role in the data submission process. Understanding the reporting mechanisms—whether through claims, EHRs, or specialized reporting systems—is critical to ensure timely and accurate submissions. Clinicians must submit their data by March 31 of the year following the performance year.
  5. Monitoring Performance: Coders can assist providers in monitoring their MIPS performance scores. By analyzing coding patterns and quality measure outcomes, they can identify areas for improvement.
  6. Education and Training: Ongoing education about MIPS requirements, quality measures, and coding best practices is essential for medical coders. Participating in workshops, webinars, and continuing education courses can enhance their knowledge and skills.
  7. Data Reporting: Eligible clinicians must report data for at least six quality measures, including one outcome or high priority measure. For the 2024 performance period, clinicians must report data for at least 75% of the denominator eligible cases for each quality measure
  8. Performance year: The MIPS performance year runs from January 1 to December 31
  9. Payment Adjustments:  Payment adjustments are applied to Medicare Part B claims between January 1 and December 31 of the year following data submission
  10. MIPS Score: The MIPS score is calculated based on four categories: quality, promoting interoperability (PI), improvement activities, and cost. The score ranges from 0–100, and determines the clinician’s payment adjustment
  11. Eligibility: Clinicians must meet specific criteria to be eligible for MIPS, such as providing care for more than 100 Medicare patients or billing more than $30,000 to Medicare Part B during a 12-month period
  12. Small Practices: A small practice is defined as 15 or fewer clinicians who have reassigned their billing rights to a single Taxpayer Identification Number (TIN). Small practices receive a six-point bonus

AAPMs

AAPMs are a subset of Alternative Payment Models (APMs) approved by CMS. In an APM, providers take on added risks to deliver high-quality care, and assume greater revenue risks and rewards.

To qualify as an Advanced Alternative Payment Model (AAPM), a program must meet three criteria: 

  • Use quality measures comparable to MIPS: Quality measures must be based on evidence and be reliable and valid. They can include measures from the Merit-Based Incentive Payment System (MIPS) final list, as well as measures from the National Quality Forum (NQF), measures submitted in the annual call for quality measures, and measures developed using QPP Measure Development funds. 
  • Require participants to use certified electronic health record technology: Participants must use certified electronic health record (EHR) technology. 
  • Participants must bear more than nominal financial risk: Participants must share in financial risk, either if actual expenditures exceed expected aggregate expenditures, or if the payment arrangement is a Medicaid Medical Home Model that meets criteria comparable to the Medical Home Model that has been expanded. 
AAPMs are a subset of Alternative Payment Models (APMs) approved by CMS. In an APM, providers take on added risks to deliver high-quality care, and assume greater revenue risks and rewards.

Deciding between AAPMs and MIPS

Choose an APM if you want to take on more financial risk for the potential of greater rewards, while MIPS is a better option if you prefer a more standardized approach with less risk; essentially, APMs are generally considered more complex and potentially more lucrative, while MIPS is simpler and offers smaller potential financial adjustments based on performance metrics.

Key differences: 

  • Risk Level:
    APMs involve greater financial risk for providers as they often tie payments directly to patient outcomes and cost management, whereas MIPS uses a more moderate risk approach based on quality measures and performance data.
  • Complexity:
    APMs tend to be more complex with detailed performance metrics and requirements, while MIPS has a more streamlined approach with established quality measures.
  • Potential Reward:

    APMs can offer significantly higher potential financial rewards for exceeding quality and cost targets, compared to the smaller potential bonuses available through MIPS. 

Who should consider APMs: 

  • Practices with a strong focus on quality improvement and coordinated care. 
  • Providers comfortable with taking on financial risk for the potential of higher returns. 
  • Organizations with well-developed infrastructure to track patient outcomes and cost data. 

Who should consider MIPS: 

  • Practices looking for a more standardized approach to quality reporting. 
  • Providers who prefer a lower level of financial risk. 
  • Smaller practices with limited resources for complex quality initiatives. 

Important points to remember: 

  • Overlap exists:

    Some APMs are considered “MIPS APMs” meaning they are still subject to some MIPS reporting requirements. 

  • Consult with your organization:
    Discuss your practice’s capabilities and goals with relevant stakeholders to determine the best payment model for your situation.

The MIPS AAPM guidelines are integral to the shift toward value-based healthcare. For medical coders, a solid understanding of these guidelines not only supports compliance but also enhances the overall quality of care provided by healthcare organizations. As the landscape of medical coding continues to evolve, staying informed about MIPS and its implications will be crucial for success in the field. By ensuring accurate coding, thorough documentation, and proactive participation in quality initiatives, medical coders can significantly impact healthcare outcomes and reimbursement processes.

 

 

Share This