How to Get Started Guide
MIPS is a Medicare quality reporting program with four weighted performance categories:
- Quality (formerly PQRS) - Measures health care processes, outcomes, and patient experiences of their care.
- Promoting Interoperability (PI) (formerly the Advancing Care Information (ACI); Meaningful Use (MU) - encourages participants to adopt, implement, upgrade, and demonstrate meaningful use of certified electronic health record technology (CEHRT).
- Improvement Activities (IA) - measures participation in activities that improve clinical practice or care delivery in a way that is likely to result in improved outcomes.
- Cost - (formerly Value-based Payment Modifier (VM) - measures the cost of services and items, and overall costs of care using Medicare Part A and B claims data to calculate cost measure performance. Participants don’t have to submit any data for this category.
Each year categories are assigned a percentage that is weighted against a final combined score of all four categories which potentially totals a maximum score of 100 points. Your final score is then compared to a performance threshold score which will determine if you receive a positive, neutral, or negative payment adjustment on your Medicare Part B payments.
The Performance Year (PY) 2023 threshold score is set at 75 points. The performance category weights are Quality 30%, PI 25%, IA 5%, and Cost 30%.
Click to view HCMS' MIPS overview video
You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments of the MIPS Determination Period, you:
• Bill more than $90,000 for Part B covered professional services, AND
• See more than 200 Part B patients, AND;
• Provide more than 200 covered professional services to Part B patients.
If you sufficiently participate in an Advanced APM, you may achieve QP status which excludes you from MIPS participation and makes you eligible for a 5% APM incentive payment. If you don't achieve QP status and are otherwise considered a MIPS eligible clinician, you'll need to participate in MIPS. Clinicians who achieve Partial QP status only need to participate in MIPS if they (or their APM Entity) submit an election to do so.
Who is exempt?
• Eligible clinicians (ECs) participating in the Medicare program for the first time in the performance year.
• ECs participating in an eligible advanced APM and qualify for incentive payments through that program.
• ECs who have less than the CMS identified participation thresholds:
- Those who have ≤ $90,000 in Medicare Part B charges; OR
- Provide care for ≤ 200 Medicare Part B patients; OR
- Provide 200 or fewer covered professional services under Part B.
Physicians who are exempt due to the low-volume threshold have the option to opt-in to 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. 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. If an individual and/or group elects to opt-in they will:
How to check clinician participation status
- 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.
Utilize the QPP Look-Up Tool
using your National Provider Identifier (NPI) to view MIPS eligibility and APM Qualifying Participant (QP) data. The toll also allows physicians to 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. For example, hospital-based special status clinicians are automatically exempt from the Promoting Interoperability category. The eligibility tool will also indicate if you are eligible to opt-in to MIPS.
Watch our instructional video to assist you with the use of the Look-Up Tool.
MIPS Exception Application(s)
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 onto the QPP website with your Enterprise Identity Data Management (EIDM) or HCQIS Access Roles and Profile (HARP) credentials, go 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.
Every MIPS performance year CMS releases Hardship Exception Applications allowing physicians to apply for an exemption to MIPS or portions of it, depending upon certain circumstances. CMS will announce dates for submitting applications, generally in late Spring. 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). The automatic EUC policy does not apply to group or virtual group participation. However, 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 scored for the performance year. Physicians are not required to submit documentation with their applications, 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.
STEP 2: Determine How to Participate
Practices who participate in MIPS may 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.
- MIPS APMs - If you are in a MIPS APM, you can participate in MIPS via the APM Performance Pathway (APP). Performance is measured across only three of the four performance categories - Quality, Improvement Activities, and Promoting Interoperability.
STEP 3: Select Your Data Submission Mechanism
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 reported through claims by CMS and does not require 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. Only one submission mechanism may be selected per category. 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.
- Claims - This mechanism is a free option that allows physicians to report their measures on a claims basis and is for the applicable performance period. Only Medicare Part B claims are used. This is only available for small practices (15 clinicians or less), whether participating as an individual, 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 in early January. 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. Watch the Video Guides for information on how to complete data submission through the QPP portal.
- 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. Review the 2023 Qualified Registries list on the QPP Resource Library page to find a registry or registries for reporting your data. Note that the data submission deadline for registries is earlier than those for MIPS to allow time for parsing and formatting the data.
- Clinical Data Registries (QCDRs) - CMS-approved QCDRs are entities that collect 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). Review the 2023 QCDR list on the QPP Resource Library page to find a registry or registries for reporting your data. Note that the data submission deadline for registries is earlier than those for MIPS to allow time for parsing and formatting the data.
- 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 reporting capabilities.
- CMS Web Interface - The CMS Web Interface is no longer available as a collection or submission type for groups, virtual groups, and APM Entities participating in traditional MIPS starting with the 2023 performance period.
- CAHPS for MIPS Survey - This 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 will be submitted on behalf of the group by the CMS-approved survey vendor. The CAHPS survey is only one portion of the 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 for PY 2023 opens April 3, 2023 and ends June 30, 2023. CAHPS for MIPS resources will be added when they become available.
STEP 4: Select Measures to Report for Each Category
: For all participants, reporting the full quality performance requires the selection of a total of six measures for both group and individuals,
one of which must be an outcome measure. If one is not available, a high priority measure or a complete specialty measure set must be selected. Review the quality measures
(select the appropriate performance year).
Scroll down to the filter options and filter measures by "Submission Method" as discussed in step 3.
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.
Promoting Interoperability (PI)
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. You must provide your EHR's CMS Identification code from the Certified Health IT Product List (CHPL). You must also submit "yes" to Actions to Limit or Restrict Compatibility or Interoperability of CEHRT (previously named the Prevention of Information Blocking) Attestation, ONC Direct Review Attestation, and Security Risk Analysis Measure, and The SAFER Guide Measure (a "no" will also satisfy this measure). Most measures include exclusions dependent on meeting certain criteria.
Improvement Activities (CPIA)
: Review the IA inventory
(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. You must generally submit one of the following combination of activities: small practices (15 clinicians or fewer) can complete 2 high-weighted activity (each worth 20 category points) or 4 medium-weighted activities (each worth 10 category points), or 2 medium and 1 high weighted activities for a consecutive 90 days to receive full credit in the IA category. Although only a "yes" or "no" attestation is needed for IA reporting purposes and no supplemental information regarding the activity is required, it is important for all practices to keep a record of the IA's they attest to in case of audit. View the recommended data validation criteria found in the QPP Resource Library
: The Cost performance category requires no measure selection or data submission and is done automatically through claims submitted to CMS using their patient attribution process. Review all cost measures
(select the appropriate performance year) and make note that only measures that are attributable to you or your practice will be used in your Cost category scoring.
STEP 5: 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 for the 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.
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 assigned to them is in error. Generally the target review period 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. To review your MIPS score and/or submit a targeted review, visit the QPP website
and login using your EIDM or HARP credentials. Targeted Review decisions are final and not eligible for further review. Examples of circumstances in which a Targeted Review may be requested are errors or data quality issues on the measures and activities 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, etc.
STEP 6: Feedback Reports
Feedback reports are made available after the submission period ends following each reporting year, and during the reporting year for claims reporting. MIPS feedback reports can be accessed through the QPP website
with your HARP credentials. Care Compare: Doctors and Clinicians Preview
allows physicians and clinicians to preview their performance information for the current 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