MIPS 2018: The Die is Cast on Part B Drugs

by | Nov 6, 2017 | MIPS

Several weeks ago I wrote a post entitled “MIPS and Medicare Part B Drugs – Waiting for the Other Shoe to Drop”. Late last week the other shoe hit the floor with the release of the Final Rule. The issue at hand is whether an Eligible Clinician’s (EC) MIPS score would impact not only their professional services reimbursement but also billed Medicare Part B drugs. These are often very expensive drugs and include those used in the treatment of such diseases as cancer and renal failure. Injected and infused drugs are included as well as those related to transplantation, osteoporosis, and numerous other conditions. The Proposed Rule indicated these Part B drug costs in most circumstances would be included in the MIPS reimbursement and eligibility calculations.

As expected, there was heavy push back during the public comment period. Here are a few samples:

  • American Society of Cataract and Refractive Surgery: “MIPS program eligibility should only be based on physician services under Part B, and exclude items such as drugs administered in the office under Part B.”
  • Medical Group Management Association: “Part B drug costs should be excluded from these calculations.”
  • Society of Interventional Radiology: “SIR continues to oppose including items or services beyond the physician fee schedule, especially Part B drugs”
  • American Society of Retina Specialists: “ASRS strongly opposes application of the MIPS payment adjustment to the cost of Part B drugs.”
  • American Society of Clinical Oncology: “CMS should not subject Part B drugs administered by medical oncologists to a MIPS adjustment.”
  • Infectious Diseases Society of America: “We strongly disagree with CMS’ policy to include Part B drugs in the calculation of MIPS payment adjustments and eligibility determinations.”
  • American Academy of Allergy Asthma and Immunology: “CMS must reconsider its proposal and exclude Part B drugs from MIPS eligibility determinations and payment adjustments.”

The release of the relevant Final Rule for 2018 last week brought disappointment to those hoping that Part B drugs would be excluded from the MIPS reimbursement and eligibility formulas. For those providers that will be affected things just got very real. ECs with a large amount of Part B drug participation need to quickly develop a strategy to achieve a high MIPS score.

Below I have posted CMS guidance that spells it out.

MACRA legislation now requires that MIPS payment adjustments be made to payments for both items and services under Medicare Part B, including Part B drugs. For each MIPS payment year, the MIPS payment adjustment factor, and, if applicable, the additional MIPS payment adjustment factor for exceptional performance are applied to Medicare Part B payments for items and services furnished by MIPS eligible clinicians during the year. These adjustments apply to all of the Medicare Part B items and services furnished by, and billed under, the combined Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) of a MIPS eligible clinician and not only to services paid under the Medicare PFS.

There are times when Medicare Part B drugs link directly to charges where the MIPS payment adjustment may apply, such as when billing Part B drugs under the PFS using modifiers. For example, the following scenario may apply to individual MIPS eligible clinicians, groups or virtual groups participating in MIPS. Scenario: You keep medication in the office and then bill Medicare for the drug as well as the office visit to administer the drug. Result: Tthe cost of the drug itself and the administration of the drug are direcrtly attributed to you by TIN/NPI.

However, if the clinician bills Medicare Part B outside of these facilities, even part-time, payment for those items and services may be subject to the MIPS payment adjustment.

For Practice Managers, Hospital Administrators, or anyone else tasked with leading a high volume Part B drug practice now is the time to act. The waiting is over.