MIPS Cost Performance Category

Accounts for 30 Percent of Final MIPS Score in 2022

The MIPS Cost category is designed to reward Eligible Clinicians (ECs) for cost-effective care and efficient use of Medicare resources. The Cost Category uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR) only the scoring is different.

This category will compare the Eligible Clinician's resource use (costs of care) against resource use data to treat similar care episodes and clinical condition groups across practices. Most RDNs will not be scored under this performance category as RDNs are not included when CMS determines providers to whom patients can be attributed for the purposes of many of the cost measures (e.g., RDNs are not primary care providers, do not bill for the majority of services a patient receives, do not bill for inpatient services). As a result, the weight for this category for most, if not all, RDNs will be shifted to the Quality Performance Category, based upon CMS belief that ECs are more familiar with quality reporting.

Reporting Requirements

This is the only MIPS performance category that the Centers for Medicare and Medicaid Services calculates entirely. No data submission by RDNs is required as administrative claims data will be used to calculate the EC's Cost Score.

What is a Cost Measure?

Generally stated, a cost measure represents the Medicare payments (for example, payments under the Physician Fee Schedule) for the items and services furnished to a beneficiary during an episode of care. The episode of care can be defined as the course of treatment for a specific illness, condition or medical event.

Why are Cost Measures Important?

They provide clinicians with actionable information that, together with the other components of the MIPS program, promote the delivery of high value care together with reduced healthcare costs and improved patient outcomes.

Cost Performance Measures

For 2022, MIPS uses cost measures that assess the beneficiary's total cost of care during the year, or during a hospital stay, and/or during eighteen episodes of care as defined below:

Total Per Capita Cost (TPCC)

  • This measure is calculated from Medicare Part A and Part B claims for inpatient hospital; outpatient hospital; skilled nursing facility; home health; hospice; and durable medical equipment, prosthetics, orthotics and supplies.
  • Costs are attributed to the primary care provider that provides the majority of primary care services to the Medicare beneficiary during the performance year.

Medicare Spending Per Beneficiary (MSPB)

  • This measure assesses the cost to Medicare of services performed by an individual clinician during episodes of care initiated by acute inpatient hospital stays. It includes all Medicare Part A and Part B claims with a start date between 3 days prior to a hospital admission through 30 days after hospital discharge. The measure looks at actual cost versus expected cost.
  • Costs are attributed to the clinician responsible for a large amount of the Part B services billed on non-institutional claims during the admission.

25 Episode - Based Measures

  • These measures look at actual cost versus expected cost for a certain medical or surgical episode of care.
  • An episode of care is triggered by a specific set of CPT/HCPCS codes and care settings that are unique to the patient journey that define the start of an episode.
  • CMS has been developing episode-based measures based on recommendations from expert clinician committees based on their high impact in terms of patient population and Medicare spending, and the opportunity for incentivizing cost-effective, high-quality clinical care. The Academy has been involved in the expert clinician committees as appropriate and will continue to do so.

Learn more about cost measures.

Cost Scoring Under MIPS

  • CMS scores Cost by calculating an individual performance category score which folds into the MIPS Composite Performance Score (CPS). While this category accounts for 30 Percent of final MIPS score in 2022, it does not apply to most RDNs and will be reweighted to the Quality Performance Category.

No Improvement Scoring Under Cost

  • At the current time, scoring under this performance category will not include a component for improvement from one year to the next. Improvement scoring will not be factored into the total Cost score until the 2024 MIPS payment year.