Understanding the MIPS Complex Patient Bonus

CMS’ Merit-based Incentive Payment System (MIPS) is a pay-for-performance program where a higher score leads to higher reimbursement. Further, MIPS is a budget neutral program where those receiving a negative payment adjustment fund those receiving a positive payment adjustment. The Complex Patient Bonus can help you achieve a higher score. 

Overview of the Complex Patient Bonus: 

The MIPS Complex Patient Bonus awards bonus points to clinicians that care for vulnerable, medically complex patients. The Complex Patient Bonus is added to the final MIPS score and clinicians can earn up to 10 bonus points based on the medical complexity and social risk of their patients 

1. Medical Complexity: uses the Hierarchical Condition Categories (HCC) Risk Scores of your Medicare patient population. These scores are assigned to each Medicare patient based on the severity of their acute or chronic conditions and are an indicator of medical complexity. 

• Hierarchical Condition Categories (HCCs): sets of medical codes that are linked to specific clinical diagnoses. More information about CPT and HCPCS codes eligible for Medicare risk-adjustment can be found here 

• HCC risk score is based on: 

• Age and sex 

• Diagnoses from the previous year 

• Whether they are eligible for Medicaid, first qualified for Medicare on the basis of disability, or live in an institution (usually a nursing home) 

2. Social Risk: uses the Dual Eligibility Ratio of your patient population. Dual Eligibility is a common indicator of social risk and refers to patients that are eligible for both Medicare and full- or partial-benefits under Medicaid. 

• CMS calculates the number of your dually eligible patients for the performance year using claims data 

• The proportion will be a comparison of unique patients who are dually eligible for Medicare and Medicaid seen by the MIPS eligible clinician to all unique Medicare patients seen by the MIPS eligible clinician during this time period 

Eligibility for the Complex Patient Bonus 

To be eligible for the Complex Patient Bonus, MIPS eligible clinicians, groups, virtual groups and APM Entities must have at least one risk indicator (either average HCC risk score or dual eligibility ratio) at or above the median risk indicator calculated for all MIPS eligible clinicians, groups, virtual groups and APM Entities from the prior performance year. 

1. CMS identifies the median HCC risk score and median dual eligibility ratio based on the complex patient bonus included in the final score attributed to each MIPS eligible clinician in the prior performance year 

2. CMS calculates the average HCC risk score and dual eligibility ratio for each of the MIPS eligible clinicians for the current performance year 

• Average HCC risk score = sum of HCC risk scores for the unique Medicare patients treated*/number of unique Medicare patients treated* 

• Dual eligibility ratio = unique Medicare patients treated* who were dually eligible for Medicare and full- or partial-Medicaid benefits/unique Medicare patients treated*  

• *Medicare patients must have been treated between October 1 (of prior performance year) and September 30 (of current performance year) to be included in these calculations 

3. CMS compares your average HCC risk score and dual eligibility ratio (calculated in Step 2) to the median values identified in Step 1 

• If either (or both) of your risk indicators is at or above the median identified in step 1, you're eligible to receive the complex patient bonus 

Calculating the Complex Patient Bonus 

1. CMS identifies the mean HCC risk score and mean dual eligibility ratio based on the complex patient bonus included in the final score attributed to each MIPS eligible clinician in the prior performance year 

2. CMS calculates a standardized score for the medical complexity component 

• Medical component standardized score = (your average HCC risk score for current performance year MINUS the prior performance year mean HCC risk score from step 1)/ standard deviation for the prior year performance mean HCC risk score from step 1 

3. CMS calculates a standardized score for the social risk component 

• Social component standardized score = (your dual eligibility ratio for current performance year MINUS the prior year performance mean dual eligibility ratio from step 1)/ standard deviation for the prior year performance mean dual eligibility ratio from step 1 

4. CMS calculates the medical complexity component contribution to your complex patient bonus 

• Medical complexity complex patient bonus points = 1.5 + [4 x (standardized score from step 2)]  

5. CMS calculates the social risk component contribution to your complex patient bonus 

• Social risk complex patient bonus points = 1.5 + [4 x (standardized score from step 3)} 

6. CMS calculates your total complex patient bonus 

• Complex patient bonus = Medical complexity points (step 4) + Social risk points (step 5)  

If only 1 of the 2 risk indicators – medical complexity or social risk – was at or above the median when CMS determined your eligibility for the complex patient bonus, then the other will contribute 0 points toward your complex patient bonus.