• Medicare Quality Payment Program (QPP)

    Merit-Based Incentive Payment System (MIPS)


    MIPS is a new Medicare reporting program that consolidates the previous quality reporting programs, which had their final performance year in 2016 and final payment year will occur in 2018:

    • Physician Quality Reporting System (PQRS)
    • Value-Based Modifier (VM)
    • EHR Inventive Program (Meaningful Use)


    MIPS began its first performance year in 2017 and has four weighted performance categories: 

    1. Quality: Formerly, PQRS, includes measures used in the existing quality performance programs, in addition to new measures developed through notice and comment rule making, and measures used by qualified clinical data registries (QCDRs).
    2. Advancing Care Information (ACI): Formerly Meaningful Use, includes current EHR Meaningful Use (MU) requirements, demonstrated by use of a certified EHR system.
    3. Clinical Practice Improvement Activities aka Improvement Activities (IA): Reflects physicians efforts to improve clinical practice or care delivery in a way that is likely to result in improved outcomes.
    4. Cost: Formerly VM, includes measures VM program, with additional refinements based on public input.
    Each year categories are assigned a percentage that is weighted against a final combined score of all four categories which amounts to a total maximum score of 100 points. Your final score is then compared to a performance threshold score which will determine if you get a positive, neutral or negative payment adjustment on your Medicare Part B payments. In 2017 the performance threshold score is set at 3 points and 2018 is set at 15. 

    For the 2017 MIPS reporting  year Quality is worth 60% of your final score, ACI is 25%, IA is 15% and Cost is not weighted (0%). In 2018 the percentages change slightly with Quality worth 50% of your final score, ACI at 25%, IA at 15% and Cost now worth 10%. 


    STEP 1: Determine Your Eligibility

    Who is eligible?

    • Eligible Clinicians = Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, as well as group practices including such professionals.


    Who is exempt?

    • Eligible clinicians (ECs) participating in the Medicare program for the first time.
    • ECs participating in an eligible advanced Alternative Payment Model (APM) and qualify for incentive payments through that program.
    • ECs who have less than a CMS identified allowed amount of Medicare Part B charges a year or provide care for less than a CMS identified number of Medicare Part B patients.
      • In 2017 these amounts are those who have less than $30,000 in Medicare Part B charges or provided care for less than 100 Medicare Part B patients.
      • In 2018 these amounts are those who have less than $90,000 in Medicare Part B charges or provided care for less than 200 Medicare Part B patients.

    There are two eligibility look-up tools available to confirm a clinician’s status in the Quality Payment Program: 

    1. Clinicians who may be included in MIPS should check their National Provider Identifier (NPI) in the MIPS Participation Status Tool, which will be updated with the most recent eligibility data, to confirm whether they are required to submit data under MIPS for 2017. 
    2. For clinicians who know they are in an MIPS APM or Advanced APM, CMS is working to improve the Qualifying APM Participant (QP) Look-up Tool to include eligibility information for Advanced APM and MIPS APM participants.  


    For additional information review this 2017 MIPS Participation Fact Sheet.

    STEP 2: Choose How to Participate

    Practices who participate in MIPS can choose to participate as individuals or as a group:

    • Individual Physicians - If you report as an individual, your payment adjustment will be based on your individual performance. An individual is identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN). If your NPI is tied to multiple TINs you will need to report MIPS for each TIN either as a group or individual.
    • Group Practices - Each eligible clinician participating in MIPS via a group will receive the same payment adjustment based on the overall group's performance. A group is defined as a single TIN with 2 or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their NPI, who have reassigned their Medicare billing rights to the TIN.


    STEP 3: Determine Your Level of Participation

    January 1, 2017 through December 31, 2017 was the first official participation year for the MIPS pathway and was considered a “transition year” by CMS. CMS is offering 3 different participation routes for 2017:


    MIPS Pathways



    2018 Participation: IT IS IMPORTANT TO NOTE that for 2018 the participation requirements are different and require a higher level of participation. In 2018 the performance threshold score was increased from three to 15, and for full participation the quality category must reported for a full year (January 1, 2018 through December 31, 2018), while ACI and IA categories must be reported for a minimum of 90 consecutive days. 


    STEP 4: Select Your Submission Mechanism(s)

    Three of the four MIPS categories, Quality, ACI, and IA have a selection of submission mechanisms that can be used to submit the data collected during the performance year for that category (cost category is done through administration claims by CMS and requires not submission by the physician or group). A submission mechanism can be selected to report all three categories together or each category may have their own submission mechanism best suited for the practice. 


    It is important to select your preferred submission mechanism for the Quality category before selecting your measures as the selection of measures differs between each mechanism. Filtering your quality measure search based upon submission mechanism will help avoid any reporting mishaps.  

    Note: Only one submission mechanism may be selected per category. 


    Submission Mechanisms:

    • Claims - this mechanism is a free option that allows physicians to report their measures on a per patient per claim basis. This option is done during the performance period as claims for only Medicare Part B patients are processed. It is only available for the quality category and those reporting as individuals (not groups). 
    • Qualified Registries - a qualified registry is a CMS-approved entity that acts as an intermediary to collect data from MIPS physicians (both individuals and groups) and submits it to CMS on their behalf for purposes of MIPS reporting. Each registry varies from being able to report data for all three of the performance categories (Quality, ACI and IA) to just one or two. Check under the Performance Categories section of each grid for this information. 
    • Qualified Clinical Data Registries (QCDRs) - CMS-approved QCDR is an entity that collects clinical data from MIPS physicians (individuals and groups) just like qualified registries described above, except the QCDR reporting option is different from a qualified registry because it is not limited to measures within MIPS. The QCDR can develop and submit special QCDR measures for CMS approval in addition to the standard measures used in Qualified Registries (i.e. specialty specific measures)
    • Electronic Health Record (EHR) - eligible clinicians can also submit data using a Health IT Vendor, which extracts data from certified EHR technology. Speak with your EHR vendor regarding MIPS capabilities. 
    • CMS Web Interface - CMS Web Interface is a secure internet-based data submission mechanism for groups of 25 or more MIPS eligible clinicians can use to report quality data to CMS. When you choose to submit data through the CMS Web Interface, you’re agreeing to report on all 15 CMS Web Interface measures.
    • CAHPS for MIPS Survey - CMS-approved survey vendor reporting mechanism is available to all MIPS groups (not individuals) to supplement their quality reporting with the CAHPS for MIPS survey. The CAHPS for MIPS survey measures patient experience and care within a group. The data collected on these surveys will be submitted on behalf of the group by the CMS-approved survey vendor. The CAHPS survey is only one portion of your quality category reporting and practices will need to select additional measures and report through an additional mechanism described above to get full credit in the quality category. 
    • 2017 CMS Data Submission System (Attestation) - In addition to the submission mechanisms listed above CMS has launched their free data submission and attestation system through the QPP website. Eligible clinicians (groups and individuals) can generate a non-certified report in either the new QPP file format or QRDA III file format and manually upload the file into the submission system. As data is entered into the system, eligible clinicians will see real-time initial scoring within each of the MIPS performance categories based on their submissions. Data can be updated at any time during the submission period. Once the submission period closes on March 31, 2018 (with the exception of the CMS Web Interface, which ends on March 16, 2018), CMS will calculate your payment adjustment based on your last submission or submission update.
      • Video Guide - This video shows users who represent groups and/or individual clinicians how they can submit data for these categories in a few specific ways.


    STEP 5: Select Measures to Report for Each Category


    For all participants, except those who choose to report using the CMS Web Interface, reporting the full quality performance requires the selection a total of 6 measures (the same requirement for whether reporting as a group or individual), one of which must be an outcome measure (or if one is not available, a high priority measure). 


    Review the MIPS quality measures here. Scroll down to the "Filter by" options and filter measures by "Data Submission Method" (as discussed in step 4). Physicians are also able to filter measures by specialty under the "Specialty Measure Set" drop-down menu to help narrow down the list of measures. 


    Groups choosing to report quality using the web interface will report 15 quality measures for a full year. To submit data as a group through the CMS Web Interface, you must register your group between April 1 and June 30 of the performance year. 


    Advancing Care Information (ACI):

    There are two portions to the ACI performance category, the base score and the performance score. The base score makes up 50% of the total ACI category score and is required to receive any points in this category (all or nothing). The perofmance score measures are additional measures that allow you to receive the remaining score of the ACI as well as bonus points. 


    View base score and performance score measures here. Be sure to note that there are two sets of measures, the "Advancing Care information Objectives and Measures" and the 2017 Advancing Care Information Transition Objectives and Measures". Be sure to read the information on the page to understand which measures you can report based on your EHR certification.  


    Improvement Activities (IA):

    The current IA inventory is listed here. Pay particular attention to the weight of each activity (medium or high) as this changes how many points the activity is worth. Small practices (groups with fewer than 15 participants) must attest to completing up to 2 medium weighted activities or 1 high weighted activity for a consecutive 90 days to receive full credit in the IA category. This requirement doubles for practices that are larger. 


    Although only attestation is needed for IA reporting purposes and no supplemental information regarding the activity is required, it is important for all practices to keep record of the IA's they attest to in case of audit. Recommended 2017 supplemental data can be found here.   



    The cost performance category of the MIPS final score is weighted at zero percent for the 2017 performance year and ten percent for the 2018 performance year. This category requires no measure selection or data submission and is done automatically through CMS by their patient attribution process. There are two cost measures:


    1. Medicare Spending Per Beneficiary (MSPB) - assesses Medicare Part A and B costs incurred during an episode.
    2. Total Per Capital Cost (TPCC) - assesses all Medicare Part A and B costs for each attributed beneficiary. 



    STEP 6: Review Payment Adjustment Information

    Beginning in 2019, eligible clinicians (ECs) will receive a composite performance score of 0 to 100 based on their 2017 performance in each of the four performance categories (as applicable). This composite score will be compared against a performance threshold which will determine the payment adjustment percent between -4 to +4 which will take affect in 2019. 

    These payment adjustment percentages change from year to year; review this MIPS Timeline to see how these change occur through payment year 2026 and later.

    Additional information on how MIPS scoring can be found on the MIPS Scoring 101 Guide


    STEP 7: Feedback Reports

    Feedback reports are made available after the submission period ends following each reporting year. 2017 performance year feedback reports will be provided in late 2018. Additional information will be added once provided by CMS.


    MIPS/APM Timeline



    The first MIPS performance year begins on January 1, 2017. Much of the MIPS score relies on the performance measurement mechanisms of previous programs (MU, PQRS, and VBM) meaning that the best thing an organization can do is to continue to improve and analyze how these three existing programs perform and are managed.

    If you submitted quality data during the last calendar year, you should have access to your Quality and Resource Use Report (QRUR). This report will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement.




    All CMS official guides and informational items related to MIPS can be found in their Resource Library.