• Medicare Quality Payment Program (QPP)

    Merit-Based Incentive Payment System (MIPS) - How to Get Started Guide


    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. Promoting Interoperability (PI): Formerly the Advancing Care Information (ACI) category which was previously Meaningful Use.
    3. Clinical Practice Improvement Activities (CPIA): 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 2018 the performance threshold score is set at 15 points. 

    For the 2018 MIPS reporting  year Quality is worth 50% of your final score, PI is 25%, IA is 15% and Cost is 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 the 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 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 or APMs can check their National Provider Identifier (NPI) in the QPP Look-Up Tool to view 2018 MIPS eligibility and APM Qualifying APM Participant (QP) data. 
    2. Clinicians can also check 2018 MIPS Clinician Eligibility at the group level and APM predictive QP status at the APM Entity level. To check your group’s 2018 QPP eligibility log into the QPP website with your EIDM credentials, browse to the Taxpayer Identification Number (TIN) affiliated with your group and access the details screen to view the eligibility status of every clinician based on their NPI.
    Within the eligibility tool physicians can also see if they are considered a "Special Status Clinician". If identified as such, these clinicians have special MIPS circumstances depending upon the specific type of special status they are associated with, for example Hospital-based special status clinicians are automatically exempt from the EHR portion (Promoting Interoperablity category) of MIPS.
    Additionally, each year CMS releases Hardship Exception Applications which allow physicians to apply for an exemption of MIPS or portions of it depending upon certain circumstances. The 2018 MIPS performance year Hardship Exception Applications are now available. There are two Hardship Exception Applications:
    • Promoting Interoperability (PI) performance category – this application (if approved) will exempt you from completing the EHR portion of MIPS and reweight this category score to zero for the 2018 performance year. 
    • Extreme and Uncontrollable Circumstances for MIPS - eligible clinicians who are impacted by extreme and uncontrollable circumstances may submit a request for reweighting of the Quality, Cost, and Improvement Activities performance categories for the 2018 performance year. 
    The deadline to submit applications is December 31, 2018. Please note that applications are reviewed annually; submission or approval of an exception application in a previous year does not roll over and a new application must be submitted. For More Information review the 2018 Exceptions FAQ 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

    2018 Participation: requirements have changed from 2017 and now 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 PI and IA categories must be reported for a minimum of 90 consecutive days. 

    If your goal is to avoid the penalty (and not seek any incentives) then it is still possible to report to MIPS without having to prepare a full year's worth of data. Below are your options for reporting:


    • Small Practices (15 clinicians or fewer)
      • Complete the CPIA category - attest to the completion of 2 medium weighted activities or 1 high weighted during a consecutive 90 day period within the performance year.
      • Complete the Quality category - report on 6 quality measures for any amount of time (will still receive 3 points per measure even if it is not the full years as required).
      • Complete the PI category - report on both the base measures (which are required) and the performance measures for a consecutive 90 day period within the performance year. Only reporting the required base measures will NOT achieve 15 points to avoid the penalty). 
      • Multiple Categories- you can choose to report a combination of any of the three options listed above. 
    • Large Practices (more than 15 clinicians)
      • Complete the CPIA category - attest to the completion of 2 medium weighted activities or 1 high weighted during a consecutive 90 day period within the performance year.
      • Complete the Quality category - report on 6 quality measures for an entire year with data completeness (60% of all qualifying patients/encounters per measure).
      • Complete the PI category - report on both the base measures (which are required) and the performance measures for a consecutive 90 day period within the performance year. Only reporting the required base measures will NOT achieve 15 points to avoid the penalty. 
      • Multiple Categories- you can choose to report a combination of any of the three options listed above. 



    STEP 4: Select Your Submission Mechanism(s)

    Three of the four MIPS categories, Quality, PI, 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, PI 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. Register to report using CMS Web Interface by June 30
    • 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.  Register to report using CMS Web Interface by June 30
    • 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 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 options and filter measures by "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. CMS web interface quality measures can be found in the QPP Resource Library under MIPS --> Quality. 


    Promoting Interoperability (PI) previously Advancing Care Information (ACI):

    There are two portions to the PI performance category, the base score and the performance score. The base score makes up 50% of the total PI category score and is required to receive any points in this category (all or nothing). The performance score measures are additional measures that allow you to receive the remaining score of the PI 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 "PI Objectives and Measures" and the "PI 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 (CPIA):

    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 (yes or no statement) 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 2018 supplement/data validation criteria can be found here.   



    The Cost performance category makes up 10 points of the MIPS final score (out of a final MIPS score of 100) for the 2018 performance year. This category requires no measure selection or data submission and is done automatically through submitted claims by CMS using 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

    Eligible clinicians (ECs) will receive a MIPS final score of 0 to 100 based on their reported data on all four performance categories (as applicable) for each performance year. This final 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 (for 2017 data) and -5 to +5 in 2020 (for 2018 data). Review this MIPS Timeline to see future payment adjustment for years beyond these.

    Additional information on how MIPS scoring can be found on the MIPS Scoring 101 Guide and HCMS' MIPS Guides

    2017 MIPS payment adjustment information is now available and can be accessed through the QPP site with your EIDM credentials

    After each reporting year, when a final payment adjustment is assessed, physicians will have the opportunity to file a "Targeted Review" if they believe the payment adjustment was assigned to them in error. Please note that targeted review decisions are final and not eligible for further review. The following are examples of circumstances in which a targeted review may be requested:

    • Errors or data quality issues on the measures and activities you submitted
    • Eligibility issues (e.g. you fall below the low-volume threshold and should not have received a payment adjustment)
    • Being erroneously excluded from the APM participation list and not being scored under the APM scoring standard
    • Not being automatically reweighted even though you qualify for an automatic reweighting due to the 2017 extreme and uncontrollable circumstances policy

    The 2019 MIPS payment adjustment (2017 MIPS reporting) targeted review period has ended. 


    STEP 7: Feedback Reports

    Feedback reports are made available after the submission period ends following each reporting year, and during the reporting year for claims reporting. 2017 MIPS feedback reports are now available and can be accessed through the QPP site with your EIDM credentials. Additionally, individual eligible clinicians who have been submitting their 2018 Quality performance category data via claims can now login to the QPP site and review performance feedback for the 2018 performance year on an ongoing basis (updated monthly).



    2018 Feedback Schedule




    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.  

    Free technical assistance is available through the TMF Health Quality Institute