Robert Blaine Lehr, MD,
2743 Northwest Expressway,
Oklahoma City, OK 73112
Minimizing MIPS Penalty for Paper-Based Practices
Disclaimer: I am not a coding or Merit-Based Incentive Payment System (MIPS) expert. I am simply a paper-based dermatologist hoping to help other paper-based dermatologists. What follows represents my opinion only.
Avoiding a MIPS penalty in 2025 for the year 2023 for paper-based dermatologists is now very difficult since Dataderm no longer supports paper-based medical records and, in fact, is now impossible because 2023 is more than half over. Fortunately, if you are a paper-based dermatology practice with 15 or fewer providers as I am, I believe there is a simple way to reduce your MIPS penalty to less than 1% in 2025. This could be completed in the last three months of 2023 with minimal effort.
As you are probably aware, non-participation in MIPS will cost you 9% of your Medicare receivables in 2025. In 2023, you will need a MIPS score of 75 points to avoid a penalty in 2025. For most non-dermatology providers, quality measures represent 30% of the MIPS score. Improvement activities represent 15% of the MIPS score and require 90 days of continuous performance. Promoting interoperability represents 25% of the score, and cost represents 30% of the score.
What follows is a way to minimize the penalty imposed in 2025 for paper-based practices with 15 or fewer providers. Because an electronic medical record is not being used, the interoperability category does not apply. Similarly, as a dermatologist, the cost category does not apply either. That leaves quality measures counting 50% and improvement activities counting 50% of the final score.
The formula for calculating the quality score is as follows:
[(points earned on up to 6 quality measures + 6 bonus points) / 60] x 50%
You receive 6 bonus points for 15 or fewer providers. The denominator “60” comes from the maximum of 6 measures multiplied by a maximum of 10 points each (which requires 70% data completeness) resulting in the maximum possible amount.
As a small practice, you only have to report on one patient for an individual quality measure to get 3 points (although I recommend reporting on 2-3 for insurance against lost claims). The free and easy way to report six quality measures is via claim-based reporting. If you submit a single patient for 6 separate quality measures, you will get 3 points for each of the 6 measures and end up with a total quality score of 20 points:
Final quality score = [(6 x 3) + 6 / 60] x 50% = 20 points
If you complete one high-weighted or two medium-weighted improvement activities, you will receive maximum points for the improvement activity category. Improvement activities require 90 days of continuous activity, so you would need to start by October 1st. Because this represents 50% of your final score, you will get 50 points.
20 quality points and 50 improvement activity points give you 70 points in total. Again, 75 points are required to avoid a penalty in 2025. Fortunately, however, MIPS scoring is not “all or nothing”. Medicare uses a linear sliding scale to determine your penalty. A low score on the sliding scale still results in a 9% penalty, but a score of 70 out of 75 should result in a minimal penalty (hopefully less than 1%).
One problem with claim-based reporting is that there are a limited number of quality measures that can be reported via claims. Below is a list of 10 of the easiest quality measures that can be submitted via claims for Medicare patients (remember Medicare Advantage patients do not count):
1. Hemoglobin A1C. Requirements: 18-75 y.o. with a prior diagnosis of diabetes. You must code an office visit and E11.9 (diabetes type 2) or E10.9 (diabetes type 1) or another diabetes E code.
>9% 3046F; <7% 3044F; 7–9% 3051F
128. BMI. Requirements: must code an office visit.
BMI = weight (kgs)/height (meters) x height (meters).
Normal G8420; High BMI (>30 kg/meters squared) G8417.
If high BMI, put in your dictation, “Counseled on lifestyle interventions including weight loss and daily exercise“.
134. Depression. Requirements: no prior depression diagnosis. Must have office visit. Must use an official screening test. The easiest one is PRIME MD PHQ:
“Over the last two weeks, how often have you been bothered by any of the following problems? 1. During the last month, have you been bothered by feeling down, depressed, or hopeless?.
2. During the past month, have you been bothered by little interest or pleasure in doing things?”
Negative G8510; Positive G8431.
A positive screen requires a follow up plan which can be as simple as asking the patient to follow up with PCP.
226. Tobacco. Requirements: must have office visit. Tobacco non-user G9903; I recommend not using this measure if the patient is a tobacco user because it becomes more complicated.
317. Hypertension. Requirements: must have office visit and no prior hypertension diagnosis. <120/80 G8783; Systolic >120 or diastolic >80 with follow up plan documented G8950. Document something like, “Recommended lifestyle modifications with exercise and Dash Diet“.
236. Controlling hypertension. Requirements must have an office visit with no procedure and must have a prior diagnosis of hypertension (use code I10).
Systolic <140 G8752 or >140 G8753; and Diastolic <90 G8754 or >90 G8755.
(You will have 2 G codes).
397. Melanoma. Requirements must have a pathology report with pT category, thickness, ulceration, and mitotic rate. Must have C43.xx code. G9428
39. Osteoporosis. Requirements: woman 65-85 y.o. without diagnosis of osteoporosis. Must have office visit.
Bone density scan ever done G8399. Not done G8400.
112. Breast cancer. Requirements: Woman 51– 74 y.o. without bilateral mastectomy. Must have office visit.
Mammogram in last 27 months G9899. No G9900.
113. Colorectal cancer. Requirements: 50–75 y.o. Must have office visit.
Fecal occult blood/flex sig/colonoscopy/fecal Immunochemical test 3017F. No test because of total colectomy or colon cancer G9711.