Merit-based Incentive Payment System (MIPS)

How to Get Started Guide

MIPS Background
MIPS is a new Medicare reporting program that consolidates the previous quality reporting programs:
  • 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:
  • Quality [PDF Download] - 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) [PDF Download] - Formerly the Advancing Care Information (ACI) category which was previously Meaningful Use.
  • Clinical Practice Improvement Activities (CPIA) [PDF Download] - Reflects physicians efforts to improve clinical practice or care delivery in a way that is likely to result in improved outcomes.
  • Cost [PDF Download] - 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 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%.

STEP 1: Determine Your Eligibility

Who is eligible?
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.

Who is exempt?
  • 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: 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. 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 opt-in policy and guide has now been made available by CMS via the 2019 Opt-In Toolkit. This toolkit offers a detailed election process guide with images to help walk physicians through the election process which is conducted via their QPP portal
 
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. 2020 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 Hardship Exception Application(s)

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, along with deadlines and updates by Performance Year.

  • Promoting Interoperability (PI) performance category– 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) for MIPS- 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).

Performance Year (PY) 2021: MIPS Hardship Exception Applications for performance year 2021 are now open. Deadline to submit application is December 31, 2021, at 7 p.m. CST.
MIPS PI

  • Beginning with the 2021 performance period, certified electronic health record technology (CEHRT) that meets the 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of the two is required for participation in the Promoting Interoperability performance category.

MIPS EUC

  • Automatic EUC policy only applies to MIPS eligible clinicians participating as individuals unless the clinician submits data for 2 or more MIPS performance categories. 

  • MIPS EUC application allows MIPS-eligible physicians (participating as individuals, groups, virtual groups, and APM entity) to avoid a payment penalty in 2023. APM entities are required to request reweighing for all performance categories.

  • States that 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.

  • Physicians have the option to opt-out completely or partially from the 2021 MIPS program by completing a hardship exemption application and indicating it is due to the COVID-19 Public Health Emergency (PHE) and be held harmless from a 2023 payment adjustment. You are not required to submit documentation with your application, however CMS suggests physicians 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.

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.

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.

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 Participation
Requirements have changed from the previous year and now require a higher level of participation. Also, for full participation the quality category must reported for a full year (Jan. 1 through Dec. 31), while PI and IA categories must be reported for a minimum of 90 consecutive days. For the 2021 performance year, the performance threshold score increased from 45 to 60 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 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 January 3, 2022 for Performance Year (PY) 2021. Once the submission period closes on March 31, 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.  Registration period officially ended on June 30, 2021. The CMS Web Interface will sunset as a collection and submission type at the end of the 2021 performance period.     
  • 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. Registration period officially ended on June 30, 2021.

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, 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.

Groups choosing to report quality using the web interface will report 10 quality measures for the full year (January 1 - December 31, 2021). To submit data as a group through the CMS Web Interface, you must have registered your group between April 1 and June 30 of the performance year 2021. CMS web interface quality measures can be found above in step 4.

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

For PY 2021, you 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. Most measures include exclusions depending upon meeting certain criteria. Review the PI measures and exclusions.

Improvement Activities (CPIA):

Review the  PY 2021 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. 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. View the recommended 2021 data validation criteria .

Cost:
The Cost performance category makes up 20 points of the MIPS final score (maximum of 100 points) for PY 2021. 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 PY 2021 Cost measures  and 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).

  • Qualifying APM participants can view their 2019 performance year CMS APM incentive payment information through the QPP website using your EIDM or HARP credentials. For more information check out this TMA article: CMS: 2019 APM Incentive Payments.
  • Practice representatives, MIPS APM Entity representatives, individual clinicians, and virtual group representatives can view their 2020 performance year payment adjustment information 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. Target review opens when payment adjustment information is released and closes 60 days after the release of the payment adjustment information. MIPS eligible clinicians have until October 1, 2021 to request a target review for the 2020 performance yearNote: Targeted Review decisions are final and not eligible for further review. View the QPP 2020 Targeted Review User Guide [PDF Download] for more information. 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.
Practices also had the option to apply for a hardship application and request reweighting of MIPS performance categories to 0%. We highly encourage practices to review their final scores and confirm for accuracy, especially if a practice chose not to submit data or submitted a hardship application. 

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 2019 MIPS data or who filed an application for an exception due to COVID-19 should not receive a 2021 payment cut. If you are receiving a penalty in error be sure to submit a Targeted Review as discussed in Step 6. 

On January 1, 2022, PY 2020 Payment Adjustments go into effect.

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 (2019 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. To get information for performance year 2021, select "2021" for Performance Year and "MIPS" for QPP Reporting Track. Then, filter by performance category and resource type.

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.