Medicare QPP

Physicians Advocacy Institute

These resources have not been updated since 2023 but the general details remain relevant. For a summary of the key changes for CY 2024, please click here.

Frequently Asked Questions Updated for 2023


2. What is an episode-based cost measure?

  1. Episode-based cost measures are measures that assess costs for episodes of care that represent a variety of conditions and procedures that are designated as high cost, have variability in resource use, or are for high impact conditions. CMS will be assessing performance for 23 episode-based measures, when applicable to the clinician. These 23 episode-based measures are illustrated in the chart below:
    Measure Category Attribution and Case Minimum Measure
    Procedural Episodes Attribution to each MIPS eligible clinician (EC) who renders a trigger service as identified by HCPCS/CPT code. The case minimum would be 10 episodes for these measures. Elective outpatient percutaneous coronary intervention
    Knee arthroplasty
    Revascularization for lower extremity chronic critical limb ischemia
    Routine cataract removal with intraocular lens (IOL) implantation
    Screening/surveillance colonoscopy
    Acute Kidney Injury Requiring New Inpatient Dialysis
    Elective Primary Hip Arthroplasty
    Femoral or Inguinal Hernia Repair
    Hemodialysis Access Creation
    Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
    Lumpectomy, Partial Mastectomy, Simple Mastectomy
    Non-Emergent Coronary Artery Bypass Graft
    Renal or Ureteral Stone Surgical Treatment
    Melanoma Resection
    Colon and Rectal Resection
    Acute inpatient medical condition episodes Attribution to each MIPS EC who bills inpatient E/M claim lines during trigger inpatient hospitalization (i.e., an MS-DRG identifying the episode group) under a TIN that renders at least 30% of inpatient E/M claim lines in that hospitalization. The case minimum would be 20 episodes for these measures. Intracranial hemorrhage or cerebral infarction
    Simple pneumonia with hospitalization
    ST-elevation myocardial infarction infarction (STEMI) with PCI
    Inpatient Chronic Obstructive Pulmonary Disease Exacerbation
    Lower Gastrointestinal Hemorrhage
    Chronic Condition Episodes Attributed to the clinician group that renders services that make up a "trigger event." A trigger event for chronic condition episode-based measures is identified by the occurrence of 2 claims billed in close proximity by the same clinician group. The case minimum would be 20 episodes for these measures. Diabetes
    Asthma/Chronic Obstructive Pulmonary Disease (COPD)

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