The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models. This is your guide to the Merit-based Incentive Payment System (MIPS) track.
MIPS adjusts Medicare Part B payments based on performance in four performance categories: quality, cost, promoting interoperability, and improvement activities.
The other QPP participation option is the Advanced Alternative Payment Model (AAPM) track.
The Merit-based Incentive Payment System (MIPS) consolidates previous quality reporting programs. The system also added a new performance category, called improvement activities (IA). Scores from the four categories are combined to establish a final score (0-100) that will be compared against a threshold. The final score is then used to determine physician payment adjustments. The categories that make up the MIPS final score are:
Physicians can participate as either individuals or groups. When reporting as a group, all ECs reporting within the tax identification number (TIN) must be included in the group’s reporting. The MIPS final score will be applied to each national provider identifier (NPI) within the TIN.
Eligible clinicians excluded from MIPS include:
ECs who meet or exceed one or two, but not all, of the low-volume threshold criteria can opt-in to participate in MIPS. ECs who opt in will be eligible for positive and negative payment adjustments. Opt-in elections must be made through the QPP Portal and are final (i.e., they cannot be rescinded). Additional information on opting in is available in the 2022 MIPS Opt-in and Voluntary Reporting Election Guide.
Physicians can check their eligibility status by entering their NPI into the QPP Participation Status Tool. Medicare uses claims data from two segments (referred to as determination periods) to determine eligibility. They update their Tool after analyzing claims for each determination period. Medicare makes determinations at both the individual and group level. A physician or group must exceed the low volume threshold in both segments to be considered eligible for MIPS.
Additional information about how CMS determines eligibility and how to understand your status is available on the QPP Webpage and the 2023 MIPS Eligibility and Quick Start Guide.
Scores for each performance category will be weighted and rolled up into the MIPS final score. MIPS final scores will be published by the Centers for Medicare & Medicaid (CMS) on the Physician Compare website(www.medicare.gov).
PERFORMANCE CATEGORY |
CATEGORY WEIGHT |
|---|---|
| Quality | 30% |
| Cost | 30% |
Promoting Interoperability |
25% |
| Improvement Activities | 15% |
All MIPS-eligible clinicians (ECs), regardless of specialty, will be compared to each other and against a performance threshold.
ECs in a large multispecialty group can report either as individuals or as a group. When reporting as a group, all ECs reporting under the group’s tax identification number (TIN) will be included. A group cannot have some ECs report as a group and others report as individuals. Under the group reporting option, all ECs must report on the same measures. If you choose to report as a group, you must report as a group across all four MIPS performance categories.
Beginning in 2026, multispecialty groups will be required to form subgroups to report MIPS Value Pathways (see below).
Physicians who have opted out of Medicare and do not accept payments from Medicare will not be affected by payment adjustments in MIPS.
Yes. While most employed physicians will report as part of a group, MIPS payment adjustments are applied at the national provider identifier (NPI) level. If an employed physician changes practices between the performance period and the payment year, the physician’s MIPS score and accompanying payment adjustment will apply to payment at the new practice. When making hiring decisions, potential employers may take your MIPS final score into consideration.
Additionally, employers may begin basing your compensation on your MIPS final score. Employed physicians will want to make sure they are appropriately compensated for a high MIPS score.
Find additional information about employment contracting on the AAFP’s Physician Employment Contracting webpage.
Reporting methods for individuals include: claims, qualified clinical data registry (QCDR), qualified registry, and electronic health records (EHR). The promoting interoperability and improvement activities categories will include attestation options through the CMS Portal(qpp.cms.gov). There is no data submission for the cost performance category, as CMS will calculate this for ECs based on Medicare claims data.
Reporting methods for groups include: claims (15 or fewer ECs only), QCDR, qualified registry, EHR, and CMS-approved survey vendor for the Consumer Assessment of Health Providers and Surveys (CAHPS) for MIPS. Groups will also be able to attest for the promoting interoperability and improvement activities performance categories.
Eligible clinicians can find approved qualified registry and QCDR vendors in the QPP resource library(www.cms.gov). ECs can find out if their EHR is certified by searching the Certified Health IT Product List (CHPL)(chpl.healthit.gov).
Solo and group practices (10 or fewer NPIs) can join together to participate in MIPS as a virtual group. A virtual group must consist of at least two TINs. Virtual groups are designed to help small practices successfully participate in MIPS.
Beginning with the 2023 performance year, individuals and groups can select their measures and activities through traditional MIPS or by electing to report an MVP. MVPs offer subset of related measures and improvement activities that are centered around a specialty, condition, or public health priority. CMS hopes MVPs will prepare more practices to transition out of fee-for-service and into alternative payment models. The MVPs for the 2023 performance period are:
CMS will continue to develop more MVPs. While MVPs are centered around a specialty or condition, there are no restrictions related to which specialties can report certain MVPs. Any MVP can be reported by any specialty.
When reporting an MVP, ECs choose from the predetermined list of measures and activities. In traditional MIPS, ECs select measures and activities from the broader CMS measure and activity inventories.
MVPs include the same four categories as traditional MIPS: quality, cost, improvement activities, and promoting interoperability. However, MVPs have fewer reporting requirements, which are outlined below.
Find additional information about MVPs on the CMS Quality Payment Program website.
Quality (30%)
Review quality measures on the CMS Quality Payment Program website.
Cost (30%)
Review cost measures on the CMS Quality Payment program website.
Promoting Interoperability (PI) (25%)
Review promoting interoperability measures on the CMS Quality Payment Program website.
Improvement Activities (15%)
Review improvement activities on the CMS Quality Payment Program website.
Clinicians without an EHR can still participate in MIPS but will not be eligible for any of the points under the PI performance category. Use of EHR technology that is not certified will result in a zero for the category.
While still possible to participate in MIPS without an EHR, the reporting requirements will be more burdensome without the use of an EHR. The reporting mechanisms available to a practice without an EHR would be claims or qualified registry. However, use of the qualified registry option would require a manual data collection process.
MVPs are a reporting option that are meant to reduce the burden of MIPS reporting and prepare practices for participation in an alternative payment model (APM). MVPs are groups of measures and activities centered around a specific condition or specialty.
Individual ECs and groups can report using an MVP. Additionally, practices may form subgroups. A subgroup allows a larger practice to report multiple MVPs, depending on which MVP is relevant to the physicians in the subgroup. For example, a multispecialty group that includes cardiology and primary care may choose to form two subgroups - a subgroup with ECs that provide cardiology care and a subgroup with ECs that provide primary care. Subgroup reporting is currently optional. However, beginning with the 2026 performance year, multispecialty groups will be required to form subgroups to report MVPs.
Learn more about MPVs in FPM Journal.
MIPS are eligible for positive or negative Medicare Part B payment adjustments of up to 9%. Distribution of payment adjustments will be made on a sliding scale and will be budget neutral. Payment adjustments will be based on the following:
Performance in each category is weighted and used to calculate a final score (0-100). Each eligible clinician’s (EC’s) or group’s final score is compared to a performance threshold to determine payment adjustments.
ECs can receive up to 10 bonus points added to their final score through the Complex Patient Bonus. The Complex Patient Bonus is based on the medical complexity (average HCC score of EC’s Medicare patient population) and social risk (proportion of EC’s Medicare patient population that is dually eligible for Medicare and Medicaid) of an EC’s patients. The complex patient bonus is limited to ECs with at least one risk indicator (HCC score or dual-eligible ratio) at or above the median indicator calculated for all ECs.
The performance threshold for the 2023 performance period is 75 points.
Payment adjustments are budget neutral and made on a sliding scale. To maintain budget neutrality, physicians with higher final scores may be eligible for a positive payment adjustment up to three times the baseline positive payment adjustment for a given year.
Payment adjustments are based on the final score from two years prior (e.g., performance in 2023 determines payment adjustments in 2025). Like the category weights, the payment adjustment increased in the first few years of the program.
Starting with the 2020 performance year, the payment adjustment is set at ±9%
The Centers for Medicare & Medicaid Services will apply the MIPS payment adjustment at the TIN/NPI level. ECs who reported as a group will all receive the same final score, but the payment adjustment will be applied at the TIN/NPI level. Payment adjustments are made at the Medicare Part B claim level.
If an EC bills under more than one TIN during the performance period, CMS will use the highest final score associated with the clinician’s NPI during the performance period to adjust payment in the payment year.
If a clinician changes TINs between the performance period and payment year, CMS will apply the final score associated with the clinician’s NPI during the performance period to the new TIN/NPI combination. For example, if a clinician practiced at TIN A during the performance period, but is practicing at TIN B during the payment year, CMS will use the final score from TIN A to apply to the payment adjustment to the new TIN B.
Physicians can submit a request for a targeted review if they believe the information submitted to CMS has calculation errors, data quality issues, or if they clinician believes CMS has made errors in assigning score to MIPS-eligible clinicians (e.g., MIPS-eligible clinicians should have been subjected to the low-volume threshold).
Yes. Exclusions from MIPS include:
Clinicians can check their MIPS-eligibility and QP status using the QPP Participation Status Tool(qpp.cms.gov).
Clinicians that meet or exceed one or two, but not all, of the low-volume threshold criteria can opt-in to participate in MIPS. Clinicians who opt-in are eligible for positive and negative payment adjustments. Opt-in elections must be made through the QPP Portal and are in effect for the applicable performance year (i.e., they cannot be rescinded).
Resident physicians in their second year of Medicare billing and who are billing under their own NPI would be subject to MIPS adjustments. Resident physicians in their first year of billing would be considered new to Medicare and excluded from MIPS.
Payments for items and services made under a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) all-inclusive payment are exempt from MIPS. However, any Medicare Part B items and services provided and billed outside of the all-inclusive payment at FQHCs and RHCs will be subject to MIPS payment adjustments. FQHCs and RHCs are still subject to the low-volume threshold.
CMS calculates the low-volume threshold at both the group and individual level, but it is up to the clinician whether they participate at the individual or group level. For example, an EC may not be eligible at the individual level, but their group may be eligible. In that instance, if all ECs in the practice participate as individuals, the EC would not be required to report. However, if the practice decides to report as a group, the EC would be included and would receive a final score and payment adjustment based on the group’s performance.
Additional information on MIPS eligibility is available on the Quality Payment Program website.
The Centers for Medicare & Medicaid Services calculates an EC’s low-volume threshold status using two claims from two determination periods. CMS will not change the low-volume status of ECs who fall below the low-volume threshold during the first review period, but not the second. ECs can check their MIPS-eligibility status using the QPP Participation Status tool (qpp.cms.gov).
The Centers for Medicare & Medicaid Services defines a small practice as 15 or fewer ECs (small practice size for virtual groups is 10 or fewer ECs). This may include NPIs excluded from MIPS. CMS determines small practice status by analyzing claims, using the same dates as those used for determining low-volume threshold status. Small practice determinations will be available through the QPP Participation Status tool (qpp.cms.gov).
There are two hardship exceptions available to ECs. This includes a significant hardship exception for the promoting interoperability category and an extreme and uncontrollable circumstances (e.g., natural disaster) exception for the quality, cost, and improvement activities categories.
A MIPS APM includes APMs that did not qualify as AAPMs. MIPS APMs do not qualify as AAPMs because they either do not meet the nominal risk criteria or the AAPM participants do not meet the payment or patient thresholds. MIPS APM participants may report the APM Performance Pathway. MIPS APMs for the 2023 performance period include:
AAFP members can contact an AAFP subject matter expert or call (800) 274-2237.
The Centers for Medicare & Medicaid Services (CMS) offers several technical assistance programs to help you successfully participate in the Merit-based Incentive Payment System (MIPS). Use this guide to help understand which program fits your needs.
The QPP Help and Support offers free videos, webinars, and online, self-paced courses to help you better understand the QPP.
Quality Payment Program Service Center
The Centers for Medicare & Medicaid Services (CMS) encourages all eligible clinicians (ECs) to access the QPP Service Center at (866) 288-8292 or QPP@cms.hhs.gov. Practices can sign up for the QPP Listserv and monthly QPP Small Practices Newsletter on the CMS Quality Payment Program website.
Quality Innovation Network - Quality Improvement Organizations (QIN-QIOs)
Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) are designed to bring together Medicare beneficiaries, physicians, and communities in data-driven initiatives that improve patient safety, make communities healthier, provide better coordinated post-hospital care, and enhance clinical quality. QIN-QIOs offer technical assistance, as well as tailored education, best practices, and tools and resources. QIN-QIOs help provide skills for transforming practices, including employing lean methodologies, assisting Medicare physicians with the transition to the QPP, and developing innovative approaches to quality improvement.
Alternative Payment Model Learning Systems
The goal of the Alternative Payment Model Learning System is to facilitate the sharing of information and promising practices. The learning system provides APM participants with specialized information needed to increase success in the Advanced APM track. For APMs that are not AAPMs, it helps practices to understand the special benefits of MIPS APMs. APM participants are provided information to access technical assistance by their APM.