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The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models.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.
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.
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%
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.
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.
Last updated: February 2020