MACRA Basics

    Merit-based Incentive Payment System (MIPS)

    The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models.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: One of Two Payment Tracks Under the Quality Payment Program (QPP)

    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.  

    MIPS Performance Categories, Weights, and Thresholds

    Each performance category carries a different weight that contributes to the MIPS final score (0-100). The weights shifted in the early years of the program, but they reached their statutorily required levels in the 2022 performance year. The information listed below reflects the permanent weights for each category. 

    MIPS Payment Adjustments

    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%

    • Final scores above the threshold (75.01-100) will receive a positive payment adjustment.
    • Final scores below the threshold (18.76-74.99) will receive a negative payment adjustment.
    • ECs in the lowest quartile (0-18.75) will receive the maximum negative payment adjustment for a performance period.
    • Final scores equal to the threshold (75) will receive a neutral payment adjustment.

    MIPS Eligibility and Participation Options

    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:

    • Eligible clinicians who provide care to less than or equal to 200 Medicare Part B patients OR have less than or equal to $90,000 in Medicare Part B allowed charges OR provide less than or equal to 200 Medicare Part B covered services.
    • Eligible clinicians in their first year of participation in Medicare.
    • Qualifying and partial qualifying Advanced Alternative Payment Model (AAPM) participants (QPs). Partial QPs may elect to report to MIPS.

    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.

    MIPS: Reporting for Each Performance Category

    Traditional MIPS and MIPS Value Pathways (MVPs)

    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:

    • Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
    • Advancing Cancer Care
    • Advancing Care for Heart Disease
    • Advancing Rheumatology Patient Care
    • Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes
    • Improving Care for Lower Extremity Joint Repair
    • Optimal Care for Kidney Health
    • Optimal Care for Patients with Episodic Neurological Conditions
    • Optimizing Chronic Disease Management
    • Patient Safety and Support of Positive Experiences with Anesthesia
    • Promoting Wellness
    • Supportive Care for Neurodegenerative Conditions

    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%)

    • Physicians reporting via traditional MIPS must select six measures, one of which must be an outcome measure.
    • Physicians reporting via an MVP select four measures from the MVP, one of which must be an outcome measure.
    • The reporting period is an entire calendar year.
    • The Centers for Medicare & Medicaid Services (CMS) will use claims data to calculate additional administrative claims measures for groups with 16 or more ECs:
      • Hospital-wide, 30-Day, All-Cause Unplanned Readmissions (HWR) Rate for MIPS Groups
      • Risk standardized, All-Cause Unplanned Admissions for Multiple Chronic Conditions (MCCs) for MIPS (calculated for groups who meet the case minimum of 18 patients with MCCs)
    • Physicians must report on 70% of patients that qualify for each measure selected, regardless of payer. If you are reporting via claims or the CMS Web Interface, only Medicare Part B patients are included. The data completeness threshold will increase to 75% in the 2024 performance year.
    • Each measure is worth up to 10 points. Scores are based on performance compared to a benchmark.
      • Measures that can be reliably scored and have a benchmark will receive 1-10 points.
      • Measures without a benchmark, that don’t meet the case minimum or data completeness criteria will receive 0 points.
      • Small practices will receive 3 points for all measures, including those that don’t have a benchmark or don’t meet the case minimum or data completeness criteria.
    • Small practices that submit at least one quality measure will receive 6 bonus points.

    Review quality measures on the CMS Quality Payment Program website.

    Cost (30%)

    • No data submission is required.
    • CMS calculates cost measures using claims data. An EC must meet or exceed the case minimum for a measure to be scored.
    • Measures in traditional MIPS include Medicare Spending per Beneficiary (MSPB) per clinician, Total per Capita Cost, and  episode-based measures.
    • Cost measures in MVPs vary depending on the focus of the MVP.
    • An EC’s performance is compared against a benchmark and assigned 1 to 10 points. The cost category score is the aggregate of all scored cost measures.
    • CMS is developing additional episode-based cost measures for use in future program years.

    Review cost measures on the CMS Quality Payment program website.

    Promoting Interoperability (PI) (25%)

    • ECs must report on a set of required measures and are scored based on performance.
    • Reporting requirements are the same for traditional MIPS and MVPs.
    • Failure to report any of the required measures will result in a score of zero for the entire performance category.
    • ECs must use 2015 Edition certified electronic health record technology (CEHRT) for the 90 days they selected to report the promoting interoperability performance category. Look up your EHR’s certification information on the Certified Health IT Product List.
    • Conduct and attest to an annual security risk analysis. A security risk assessment is also a requirement of the Health Insurance Portability and Accountability Act (HIPAA) and should be performed by all covered entities annually, regardless of MIPS participation. Access security risk assessment tools on HealthIT.gov.
    • Complete and attest to an annual self-assessment using the High Priority Practices Guide (a part of the Safety Assurance Factors for EHR Resilience [SAFER] Guides) within the calendar year. Additional information is available on the SAFER webpage.
    • Attest “yes” to The Actions to Limit or Restrict Compatibility of Interoperability of CEHRT Attestation and the Office of the National Coordinator for Health Information Technology Direct Review Attestation.
    • ECs can apply for a hardship exception. If granted, the PI category weight will be reassigned to the quality category.
    • PI category is automatically reweighted for small practices (15 or fewer ECs)

    Review promoting interoperability measures on the CMS Quality Payment Program website.

    Improvement Activities (15%)

    • Physicians in traditional MIPS will report two high-weighted activities (20 points each) or four medium-weighted activities (10 points each), or a combination of both to achieve a total of 40 points.
    • Physicians reporting an MVP will report a combination of activities from the MVP for a total of 40 points. Activities are double weighted in MVPs.
    • Eligible clinicians in small practices (15 or fewer clinicians), rural practices, or health professional shortage areas (HPSA) can report one high-weighted activity or two medium-weighted activities (measures are double weighted).
    • Practices can attest to being a certified or recognized patient-centered medical homes (PCMH) and receive full credit.
    • Activities must be completed for at least 90 consecutive days. At least 50% of ECs within a group must perform the same activity during any continuous 90-day period in the same performance year.

    Review improvement activities on the CMS Quality Payment Program website.

    MIPS Reporting Options

    Additional reporting resources

    Last updated: February 2020