Merit-based Incentive Payment System (MIPS)

How to Get Started Guide

2022 MIPS Overview 

MIPS Background
MIPS is a new Medicare reporting program that consolidates the quality reporting components from the previous CMS program: 
  • Physician Quality Reporting System (PQRS)
  • Value-Based Modifier (VM)
  • EHR Incentive Program (Meaningful Use)
MIPS began its first performance year in 2017 and has four weighted performance categories: 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.

MIPS thresholds and category weights
Performance Year (PY) 2021: The performance threshold score is set at 60 points and the performance categories are as followed: Quality is 40% of your final score, PI is 25%, IA is 15%, and Cost is worth 20%.

Performance Year (PY) 2022: The performance threshold score is set at 75 points, with the exceptional performance threshold set at 89 points (last year of exceptional performance threshold), and the performance categories are as followed: Quality is 30% of your final score, PI is 25%, IA is 15%, and Cost is worth 30%. 

STEP 1: Determine Your Eligibility

Who is eligible?
For 2021 performance year
Eligible clinicians include, physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, registered dietitian or nutrition professionals, as well as group practices including such professionals.

For 2022 performance year
CMS will include clinical social workers and certified nurse mid-wives as part of MIPS eligible clinicians, in addition to the established eligible clinicians from the 2021 performance year.

Who is exempt?
For 2021 and 2022 performance years
  • First Year in Medicare: Eligible clinicians (ECs) participating in the Medicare program for the first time.
  • Alternative Payment Model (APM) Participation: ECs participating in an eligible advanced APM and qualify for incentive payments through that program.
  • Low-Volume Threshold: 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 2020 these amounts are:
    1. Those who have less than $90,000 in Medicare Part B charges; OR
    2. provided care for less than 200 Medicare Part B patients; OR
    3. provide 200 or fewer covered professional services under the Physician Fee Schedule. 
Opt-in Policy
Starting in PY 2019, physicians who are exempt due to the low-volume threshold have the option to opt-in to participating in MIPS. MIPS eligible clinicians and groups can elect to opt-in if they exceed one or two, but not all three, elements of the low-volume threshold criteria. If an individual and/or group elects to opt-in they will:
  • Be considered MIPS eligible clinicians and be required to report data to MIPS, if they are not otherwise excluded (i.e. one of the other exemption reasons or is not an eligible clinician type);
  • Receive performance feedback;
  • Receive a MIPS payment adjustment (either positive, neutral, or negative depending upon their final MIPS score);
  • Be eligible to have their data published on Doctors & Clinicians on Medicare Care Compare, formerly known as Physician Compare; and
  • Be assessed in the same way as MIPS eligible clinicians who are required to participate in MIPS.
It is important to note that the decision to elect to opt-in to MIPS for a performance period is binding and irreversible. Clinicians considering this option should explore the program requirements, measures and activities to ensure they can meaningfully and successfully participate. To find more information over the PY 2022 opt-in details, please visit the QP PY 2022 QPP How MIPS Eligibility is Determined, Opt-in section (make sure you are selecting the drop down "Performance year 2022" at the top of the page).
 
How to check clinician participation status
There are two ways to confirm a clinician’s status in the Quality Payment Program and find out if they are required to participate for a particular performance period:
  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 MIPS eligibility and APM Qualifying Participant (QP) data. Eligibility for the current performance year is generally finalized at the end of the performance year. 2021 eligibility data is now available on the tool, watch our instructional video below to assist with the use of the NPI tool.



  2. Clinicians can also check MIPS Clinician Eligibility at the group level and APM predictive QP status at the APM Entity level. To check your group’s QPP eligibility log into the QPP website with your Enterprise Identity Data Management (EIDM) or HCQIS Access Roles and Profile (HARP) 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 Interoperability category) of MIPS. The eligibility tool will also indicate if you are eligible to opt-in to MIPS as discussed above. 

MIPS Exception Application(s)

Every MIPS performance year CMS releases Hardship Exception Applications allowing physicians to apply for an exemption of MIPS or portions of it, depending upon certain circumstances. Below are two Hardship Exception applications:

  • MIPS Promoting Interoperability (PI) performance category Hardship Exception – Eligible clinicians, groups, and virtual groups may submit a request and if approved, will exempt you from completing the EHR portion of MIPS and reweight this category score to zero for the performance year, whether reporting traditional MIPS or APM Performance Pathways (APP). Not available for APM Entities.

  • Extreme and Uncontrollable Circumstances (EUC) Exception - Eligible clinicians, groups, and virtual groups who are impacted by extreme and uncontrollable circumstances, such as COVID-19, may submit a request for reweighting of all performance categories for the performance year, whether reporting traditional MIPS or APM Performance Pathways (APP).

    • An automatic EUC policy is available and ONLY applies to MIPS eligible clinicians participating as individuals, unless the clinician submits data for 2 or more MIPS performance categories or has a higher final score from group or APM entity participation. 

    • Under the EUC policy, groups and eligible clinicians who submit data in at least two MIPS categories will override the hardship exception and will be eligible to earn a bonus or potentially be subject to a penalty.

    • Under the EUC policy, MIPS-eligible physicians (participating as individuals, groups, virtual groups, and APM entity) have the opportunity to opt-out completely or partially from the 2021 MIPS program and indicate the extreme and uncontrollable circumstance to avoid a payment penalty in 2023. APM entities are required to request reweighing for all performance categories.

    • You are not required to submit documentation with your application, however CMS suggests physician retain documentation of their circumstances supporting their application for their own records in the event they are selected by CMS for data validation or audit.

2021 Performance Year
MIPS Hardship Exception applications are currently available. The deadline to submit an application is December 31, 2021, at 7 p.m. CST.

Due to the Texas Winter Storm, CMS extended the Automatic Extreme and Uncontrollable Circumstance (EUC) Policy to MIPS eligible clinicians (participating as individuals) identified as located in a CMS-designated region and subject to MIPS will have all 4 performance categories reweighed at zero percent, unless they submit data for 2 or more performance categories. Find additional information regarding the Automatic EUC Policy on the 2021 MIPS Automatic EUC Policy Fact Sheet.

As of November 10, 2021, CMS is applying the MIPS automatic EUC policy for the 2021 performance year due to the continuing COVID-19 Public Health Emergency (PHE). 

NOTE: Submitting any MIPS data for a performance category will override the hardship exception application on a category-by-category basis and physicians will be scored on their submission. When fewer than two performance categories can be scored physicians will receive a neutral payment adjustment in 2023 (i.e., your payment rate will stay the same). Physicians will be notified via email on the status of their application. Find additional information and application instructions on the 
QPP Exceptions Webpage.

2022 Performance Year
MIPS Hardship Exceptions applications will open late spring of PY 2022 and the deadline is December 31, 2022, at 7pm CST. 

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 two 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

2021 and 2022 Participation

For full participation, the quality category must be reported for the entire performance year (Jan. 1 through Dec. 31), while PI and IA categories must be reported for a minimum of 90 consecutive days or more.

For the 2021 performance year, the performance threshold score is set at 60 points.
For the 2022 performance year, the performance threshold score increased to 75 points. 


STEP 4: Select Your Data 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. The 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 for small practices (15 clinicians or less), whether participating as an individua, group, virtual group, or Alternative Payment Model (APM) Entity. 
  • QPP Portal - CMS offers 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. The QPP portal will open for submission on January 3, 2022 for Performance Year (PY) 2021. Once the submission period closes on March 31 at 7 pm (CST), CMS will calculate your payment adjustment based on your last submission or submission update.
    • Video Guides - CMS has uploaded videos to their YouTube channel which provide education on how to complete data submission through the QPP portal. Review their video library for videos you may find useful.
  • 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 are agreeing to report on all 10 CMS Web Interface measures (whether you are planning to submit data for 2021 or 2022).  Registration period for2022 PY opens April 1, 2022 and ends June 30, 2022.CMS Web Interface will be extended as a collection and submission type in traditional MIPS for registered groups, virtual groups and APM Entities with 25 or more clinicians for the 2022 performance period. It will continue to be a reporting option for Medicare Shared Savings Program ACOs through 2024.
  • CAHPS for MIPS Survey - CMS-approved survey vendor reporting mechanism is available to all MIPS Groups, Virtual groups, or APM Entities (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. Registration period for 2021 PY officially ended on June 30, 2021. Similar to the CMS Web Interface registration period, registration for 2022 PY opens April 1, 2022 and ends June 30, 2022. 2022 CAHPS for MIPS resources will be added when they become available.

STEP 5: Select Measures to Report for Each Category


Quality:

For all participants (2021 and 2022 PY), except those who choose to report using the CMS Web Interface, reporting the full quality performance requires the selection a total of six measures (the same requirement 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, or a complete specialty measure set.

Review the MIPS quality measures. Be sure to select the appropriate performance year. 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. The 2022 Quality Measures List [Excel sheet Download] is now available, with a total of 200 quality measures available for the 2022 PY.

Groups choosing to report quality using the web interface will report 10 quality measures for the full 2022 performance year (January 1 - December 31, 2022). 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 2022. CMS web interface quality measures can be found above in step 4.

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

For the 2021 PY and 2022 PY, MIPS eligible physicians are required to use an Electronic Health Record (EHR) that meets the 2015 Edition certification criteria, or 2015 Edition Cures Update certification criteria, or a combination of both. You must also submit collected data for certain measures organized under four objectives for the same 90 continuous days (or more) during the reporting performance year (i.e., 2022). In addition, you must provide your EHR's CMS Identification code from the Certified Health IT Product List (CHPL) and submit "yes" to: Prevention of Information Blocking Attestation, ONC Direct Review Attestation, and Security Risk Analysis measure. For 2022 PY, CMS added an additional required measure called "The SAFER Guide" that you must submit a "yes" to. Most measures include exclusions depending upon meeting certain criteria. Review the PI measures and exclusions (Be sure to select the appropriate performance year).

Improvement Activities (CPIA):

Review the PY 2022 IA inventory and make sure the appropriate performance year is selected. Pay particular attention to the weight of each activity (medium or high) as this changes how many points the activity is worth. You must generally submit one of the following combination of activities: two medium weighted activities or one high weighted activity, for a consecutive 90 days to receive full credit in the IA category. Small practices (groups with fewer than 15 participants)  will receive double points for each activity submitted.

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. View the recommended 2022 data validation criteria found in the QPP Resource Library.

Cost:
The Cost performance category for 2022 PY makes up 30 points of the MIPS final score (maximum of 100 points). This category requires no measure selection or data submission and is done automatically through submitted claims by CMS using their patient attribution process. Review all 2022 PY Cost measures  and make note that only measures that are attributable to you or your practice will be used in your Cost category scoring.

 

STEP 6: Review Payment Adjustment Information

Eligible clinicians (ECs) will receive a MIPS final score of zero to 100 based on their reported data on all four performance categories (as applicable) for each performance year. The MIPS final score and payment adjustment information will be included in the feedback report, which will be released in the Summer/Fall following the submission period of each reporting 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), -5 to +5 in 2020 (for 2018 data), -7 to +7 in 2021 (for 2019 data) and -9 to +9 in 2022 and beyond (for 2020 data and beyond).

  • PY 2020 payment adjustments go into effect Jan. 1, 2022 and can be viewed through the QPP website using your EIDM or HARP credentials. 

Targeted Review
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. Generally target review periods opens in the summer of the reporting year, when payment adjustment information is released, and closes 60 days after the release of the payment adjustment information. For PY 2022, the targeted review will open Summer 2023 and close 60 days from opening date. To review your MIPS score and/or submit a targeted review, visit the QPP website and login using EIDM or HARP credentials.

Note: 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.

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, 2018, 2019, and 2020 MIPS feedback reports are now available and can be accessed through the QPP website with your HARP credentials. Physicians who did not submit any 2020 MIPS data or who filed an application for an exception due to COVID-19 should not receive a 2022 negative or positive payment adjustment. The following feedback report will be for PY 2021. If you see that you are receiving a penalty in error be sure to submit a Targeted Review as discussed in Step 6. 

Doctors and Clinicians Preview
The doctors and clinicians preview period for the 2020 performance year closed on December 14, 2021, at 7pm (CST). This preview period allows clinicians and groups to preview their performance information for the 2020 performance year before the data are publicly reported on Medicare Care Compare and the Provider Data Catalog (PDC). To gain access, log into the QPP website. For more information, refer to the Doctors and Clinicians Preview Period User Guide.

How Can I Prepare for MIPS?

  1. Learn the MIPS process as outlined in this MIPS page
  2. Check out our 2022 MIPS Step-by-Step guide and 2021 MIPS Step-by-Step guide, also located in our Quality Tools and Resources page: Includes quick summary guides (categorized by performance years) are available from QPP's final rule summary, MIPS data collection and submission guide, to step-by-step calculations on how to calculate your MIPS score. 
  3. Improve on the previous performance year measures (if applicable): Much of the MIPS score relies on the performance measurement mechanisms of previous programs (MU, PQRS, and VBM) meaning that one of the best things an organization can do is to continue to improve and analyze their previous performance from these legacy programs as well as their previous MIPS performance on their QPP account. Take a look at the latest results at-a-glance of the Quality Payment Program Participation in 2020

Resources

All CMS official guides and informational items related to MIPS can be found in their Resource Library. To get information for performance year 2022, select "2022" for Performance Year and "MIPS" for QPP Reporting Track. Then, filter by performance category and resource type.

Free technical assistance is available through the TMF Health Quality Institute under CMS' Small , Underserved, and Rural Support (SURS) technical support initiative until February 15, 2022. For more information on the SURS initiative, visit QPP's Support for Small Practices page.  
TMF Health Quality Institute offers a free online application called TMF MIPS Toolbox  to help clinicians organize and monitor their participation in MIPS. Sign up or log in to get started.