The Cost performance category is worth 30 percent of the Merit-based Incentive Payment System (MIPS) final score in 2025.
There are no reporting requirements for the Cost performance categories.
CMS will automatically calculate cost measures for the 2025 performance period based on administrative claims data.
The MIPS cost category includes multiple cost measures. However, CMS will only hold a clinician or group accountable for a measure if the clinician or group is attributed a sufficient number of beneficiaries under a measure.
Note that a MIPS-eligible surgeon who participates in a MIPS APM and reports to traditional MIPS at the APM Entity level will not be scored on cost. Instead, the cost performance category will be reweighted to 0 percent under if the APM Entity reports quality and improvement activity data.
Cost measures that will be used in 2025 include the Total Per Capita Cost (TPCC) for all attributed Medicare Beneficiaries measure, the Medicare Spending per Beneficiary (MSPB) measure, and multiple episode-specific cost measures. CMS added six new episode-based cost measures and modified two existing episode-based measures for 2025. The episode-based cost measures relevant to surgeons for 2025 are listed below:
- Kidney Transplant Management
- Elective Outpatient Percutaneous Coronary Intervention (PCI)
- Knee Arthroplasty
- Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Cataract Removal with Intraocular Lens (IOL) Implantation
- Screening/Surveillance Colonoscopy
- Elective Primary Hip Arthroplasty
- Femoral or Inguinal Hernia Repair
- Hemodialysis Access Creation
- Lower Gastrointestinal Hemorrhage (applies to groups only)
- Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
- Non-Emergent Coronary Artery Bypass Graft (CABG)
- Renal or Ureteral Stone Surgical Treatment
- Melanoma Resection
- Colon and Rectal Resection
It is more likely that surgeons could be attributed to the MSPB measure than the TPCC measure based on the attribution methodologies. The MSPB measure assesses Medicare Part A and B costs related to the care provided to a beneficiary during an episode defined as three days prior to a hospital admission (known as the "index admission") through 30 days after hospital discharge. A "surgical episode" is attributed to the surgeon(s) who performed any related surgical procedure during the inpatient stay (i.e., identified through surgical Medicare Severity Diagnosis Related Groups (MS-DRGs)), as well as to the Taxpayer Identification Number (TIN) under which the surgeon(s) billed for the procedure. A surgeon (or TIN) must be attributed at least 35 patients under this measure to be scored on it.
For the episode-based cost measures, CMS will continue to use the following attribution methodologies:
- For acute inpatient medical condition episode-based measures: An episode is attributed to each MIPS-eligible clinician who bills inpatient evaluation and management (E/M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30 percent of the inpatient E/M claim lines in that hospitalization. A clinician or group must be attributed a minimum of 20 episodes to be scored on this type of measure.
- For procedural episode-based measures: An episode is attributed to each MIPS-eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes. A clinician or group must be attributed a minimum of 10 episodes to be scored on this type of measure.
Also note that if you meet the definition of a facility-based clinician or group, CMS may use your Hospital Value-Based Purchasing (VBP) Program score in lieu of a MIPS score if the VBP score translates to a higher score than the clinician's combined Quality and Cost score under MIPS. This policy can only help clinicians earn a higher score and does not require any special action or election on the part of the facility-based clinician.
Additional information about the cost category, including a Quick Start Guide and more detailed specifications for each measure, are available through the QPP Resource Library. CMS also offers a Cost Category fact sheet, which provides more details about the methodology for attributing and scoring these measures.
