2020 MIPS Cost Measures

Cost IdMeasure NameTypeDetailsMeasure DescriptionFull Specifications
001Medicare Spending Per Beneficiary (MSPB)All patient
Details
The revised MSPB clinician measure assesses the cost to Medicare of services provided to a beneficiary during a revised MSPB clinician episode (hereafter referred to as the “episode”), which comprises the period immediately prior to, during, and following the beneficiary’s hospital stay. An episode includes Medicare Part A and Part B claims with a start date between 3 days prior to a hospital admission (also known as the “index admission” for the episode) through 30 days after hospital discharge, excluding a defined list of services that are unlikely to be influenced by the clinician’s care decisions and are, thus, considered unrelated to the index admission. In all supplemental documentation, the term “cost” generally means the Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts Medicare spends on traditional, fee-for-service claims.Read More
002Total Per Capita Costs (TPCC)All patient
Details
The revised TPCC measures the overall cost of care delivered to a beneficiary with a focus on the primary care they receive from their provider(s). The measure is a payment-standardized, risk-adjusted, and specialty-adjusted measure. The revised measure is attributed to clinicians, who are identified by their unique Taxpayer Identification Number and National Provider Identifier pair (TIN-NPI) and clinician groups, identified by their TIN number. The revised TPCC measure can be attributed at the TIN or TIN-NPI level.Read More
011Renal or Ureteral Stone Surgical TreatmentProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Renal or Ureteral Stone Surgical Treatment episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive surgical treatment for renal or ureteral stones during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 90 days prior to the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
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012Non-Emergent Coronary Artery Bypass Graft (CABG)Procedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Non-Emergent CABG episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a CABG procedure during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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013Lumpectomy, Partial Mastectomy, Simple MastectomyProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Lumpectomy, Partial Mastectomy, Simple Mastectomy episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo partial or total mastectomy for breast cancer during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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014Lower Gastrointestinal Hemorrhage Measure Cost MeasureAcute inpatient medical condition
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Lower Gastrointestinal Hemorrhage episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 35 days after the trigger.
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015Lumbar Spine Fusion for Degenerative Disease, 1-3 LevelsProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgery for lumbar spine fusion during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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016Inpatient Chronic Obstructive Pulmonary Disease (COPD) ExacerbationAcute inpatient medical condition
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Inpatient COPD Exacerbation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient treatment for an acute exacerbation of COPD during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 60 days after the trigger.
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017Hemodialysis Access CreationProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Hemodialysis Access Creation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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018Femoral or Inguinal Hernia RepairProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Femoral or Inguinal Hernia Repair episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgical procedure to repair a femoral or inguinal hernia during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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019Elective Primary Hip ArthroplastyProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive an elective primary hip arthroplasty during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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020Acute Kidney Injury Requiring New Inpatient DialysisProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive their first inpatient dialysis service for acute kidney injury during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
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003Routine Cataract Removal with Intraocular Lens (IOL) ImplantationProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.1,2
The Routine Cataract Removal with IOL Implantation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for routine cataract removal with IOL implantation during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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004Intracranial Hemorrhage or Cerebral InfarctionAcute inpatient medical condition
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The Intracranial Hemorrhage or Cerebral Infarction episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient treatment for cerebral infarction or intracranial hemorrhage during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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005Knee ArthroplastyProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The Knee Arthroplasty episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive an elective knee arthroplasty during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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006Elective Outpatient Percutaneous Coronary Intervention (PCI)Procedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The Elective Outpatient PCI episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
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007Simple Pneumonia with HospitalizationAcute inpatient medical condition
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The Simple Pneumonia with Hospitalization episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient treatment for simple pneumonia during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
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008Revascularization for Lower Extremity Chronic Critical Limb IschemiaProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The Revascularization for Lower Extremity Chronic Critical Limb Ischemia episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
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009Screening/Surveillance ColonoscopyProcedural
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The Screening/Surveillance Colonoscopy episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a screening or surveillance colonoscopy procedure during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 14 days after the trigger.
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010ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)Acute inpatient medical condition
Details
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, which includes both Medicare and trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
The STEMI with PCI episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who present with STEMI indicating complete blockage of a coronary artery who emergently receive PCI as treatment during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
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