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:
  • 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:
  • 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).
  • Promoting Interoperability (PI) - Formerly the Advancing Care Information (ACI) category which was previously Meaningful Use.
  • 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.
  • 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 2019 the performance threshold score is set at 30 points.

For the 2019 MIPS reporting year, Quality is worth 45% of your final score, PI is 25%, IA is 15%, and Cost is worth 15%.

STEP 1: Determine Your Eligibility

Who is eligible?
Eligible Clinicians = 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.

Who is exempt?
  • First Year in Medicare: Eligible clinicians (ECs) participating in the Medicare program for the first time.
  • APM Participation: ECs participating in an eligible advanced Alternative Payment Model (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 2019 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: Beginning in 2019 clinicians 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. If an individual and/or group elects to opt-in they will:
  • Be considered MIPS eligible clinicians if they are not otherwise excluded (i.e. one of the other exemption reasons or is not an eligible clinician type);
  • Receive a MIPS payment adjustment (either positive/neutral/negative depending upon their final MIPS score);
  • Be eligible to have their data published on Physician Compare; and
  • Be assessed int he same way as MIPS eligible clinicians who are required to participate in MIPS and are therefore automatically included.
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.
The ability to opt-in for the 2019 MIPS performance year has not yet been finalized by CMS. Once this becomes available CMS will provide additional information.

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. 2019 eligibility data is now available on the tool, but is only preliminary and may display only MIPS participation status (no APM information).
  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 EIDM or 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 Interoperablity category) of MIPS. The eligibility tool will also indicate if you are eligible to opt-in to MIPS as discussed above. 

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. Below are two Hardship Exception Applications. The MIPS performance year Hardship Exception Applications for 2019 will become available around August 2019.
  • 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 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 performance year.

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

2019 Participation
Requirements have changed from 2018 and now require a higher level of participation. In 2019 the performance threshold score was increased from 15 to 30 points, and for full participation the quality category must reported for a full year (Jan. 1 through Dec. 31, 2019), while PI and IA categories must be reported for a minimum of 90 consecutive days.

Unlike 2018, if your goal is to avoid the penalty in 2019 then clinicians will need to report at least two of the three reportable categories (Quality, PI, and CPIA).

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. 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 those reporting as Individuals (not Groups).
  • 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 Jan. 2, 2019. Once the submission period closes on April 2, 2019 (with the exception of the CMS Web Interface, which ends on March 16, 2019), 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’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.

STEP 5: Select Measures to Report for Each Category

Quality:
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 six 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. 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.

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):

For 2019 there is only a single set of measures organized under four objectives. Most measures include exclusions depending upon meeting certain criteria. Review these measures and exclusions here.

Improvement Activities (CPIA):

The current IA inventory is listed here. Select the appropriate performance year. 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 two medium weighted activities or one 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 2019 data validation criteria can be found in the Resource Library, be sure to search for "MIPS Data Validation Criteria" and select the appropriate performance year.

Cost:
The Cost performance category makes up 15 points of the MIPS final score (out of a final MIPS score of 100) for the 2019 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. Review all Cost measures here, please not 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. 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).

2017 MIPS payment adjustment information as well as preliminary 2018 scoring information is now available and can be accessed through the QPP website with 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. 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.
The 2020 MIPS payment adjustment (2018 MIPS reporting) targeted review period has not yet occurred, but will most likely open in late 2019 after 2018 data has been scored.

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 website with your EIDM or HARP credentials. MIPS 2018 preliminary performance feedback data is also available for those practices that submitted data through the QPP website, keep in mind this is not your final score or feedback. Final results will be available July 2019.

How Can I Prepare for MIPS?

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 their previous performance from these legacy programs as well as their MIPS performance on their QPP profiles (2017 performance information is currently available). For assistance with this process, contact us at quality@hcms.org.

Resources

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.