Merit-based Incentive Payment System (MIPS)

Report Your 2018 MIPS Data

Report your 2018 MIPS performance data on the CMS Portal by April 2, 2019 to avoid a 5% negative payment in 2020.

MACRA Basics

Merit-based Incentive Payment System (MIPS)

New: 2019 MIPS Playbook

Get the AAFP's newest guide to navigating the Merit-based Incentive Payment System (MIPS)..

Free for Members

 

Report Your 2018 MIPS Data

Report your 2018 MIPS performance data on the CMS Portal by April 2, 2019 to avoid a 5% negative payment in 2020.

More on the MIPS Performance Categories

Want to dig deeper into the performance categories associated with MIPS?

MIPS: One of Two Payment Tracks Under the Quality Payment Program (QPP)

The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models. The Merit-based Incentive Payment System (MIPS) track replaced three existing quality programs and added a new performance category.

Quality Payment Program (QPP) Changes for 2019

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released updates to the QPP for the 2019 performance period. Major program changes include:

  • Opt-in Pathway – ECs who 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 Opt-in elections are effective for the applicable performance year (i.e., they cannot be rescinded)
  • Additional low-volume threshold criteria – ECs who provide care to less than or equal to 200 Medicare Part B beneficiaries or received less than or equal to $90,000 in Medicare Part B payments or provided less than or equal to 200 Medicare Part B covered services are excluded from MIPS. ECs can check their MIPS-eligibility status using the QPP Participation Status Tool(qpp.cms.gov).
  • Increased cost weight/decreased quality weight – The weight of the cost category has increased to 15% for the 2019 performance period. The weight of the quality category has decreased to 45%. The cost performance category will gradually increase until it reaches 30% in performance year 2022.
  • Increased performance threshold – The performance threshold has increased to 30 points for the 2019 performance year.
  • Requiring 2015 Edition CEHRT – ECs must use 2015 Edition CEHRT for the 90 days they are reporting the promoting interoperability performance category.
  • Update to the small practice bonus – Eligible clinicians (ECs) in small practices (15 or fewer clinicians) will receive a six-point bonus added to their quality performance category score.

Merit-based Incentive Payment System (MIPS) Overview

The Merit-based Incentive Payment System (MIPS) is one of the two payment tracks created under MACRA; the other is the Advanced Alternative Payment Model (AAPM) track. MIPS adjusts payment based on performance in four performance categories:

Performance categories carry different weights that will shift as the program progresses.

Performance Periods
Performance Periods: Performance Category201920202021
Performance Periods: Quality45%40%**35%**
Performance Periods: Cost15%20%**25%**
Performance Periods: Promoting Interoperability
25%*25%*25%*
Performance Periods: Improvement Activities15%15%15%

*If the Secretary of the U.S. Department of Health and Human Services (HHS) determines the proportion of eligible clinicians who are “meaningful users of electronic health records (EHRs)” is estimated at 75% or greater, the weight of the PI category may be reduced. The remaining performance categories will be increased by the corresponding number of percentage points. The lowest weight the PI category can carry is 15%.

**Anticipated category weights

Performance in each category is weighted and used to calculate a final score (0-100). Each EC or group’s final score is compared to a performance threshold to determine payment adjustments. The performance threshold for the 2019 performance period is 30 points.

  • Final scores above the threshold will receive a positive payment adjustment.
  • Final scores below the threshold will receive a negative payment adjustment.
  • ECs in the lowest quartile will receive the maximum payment adjustment for a performance period.
  • Final scores equal to the threshold will receive a neutral payment adjustment.

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, based on the final score, are based on performance from two years prior (e.g., performance in 2019 determines payment adjustments in 2021). Adjustments are made on the following sliding scale:

Performance Year

Payment Year

Potential Positive/Negative Payment Adjustment

Performance Year

:

2018

Payment Year

:

2020

Potential Positive/Negative Payment Adjustment:

±5%

Performance Year

:

2019

Payment Year

:

2021

Potential Positive/Negative Payment Adjustment:

±7%

Performance Year

:

2020

Payment Year

:

2022

Potential Positive/Negative Payment Adjustment:

±9%

Performance Year

:

2021

Payment Year

:

2023

Potential Positive/Negative Payment Adjustment:

±9%

 

Exceptional performers that meet the additional performance threshold could receive an additional sliding scale positive payment adjustment of up to 10%. The exceptional performance threshold for the 2019 performance period has been set at 75. Exceptional performance adjustments occur outside of budget neutrality.

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. Additionally, a TIN cannot be split into multiple groups.

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 who qualify for the AAPM bonus. 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(qpp.cms.gov) and are final (i.e., they cannot be rescinded).

MIPS Performance Categories

Note: percentage weights and criteria based on the 2019 performance period.

Quality – 45%

  • Physicians report six measures, one of which must be an outcome measure.
  • The Centers for Medicare & Medicaid Services (CMS) will use claims data to calculate the all-cause hospital readmission measure for groups of 16 or more eligible clinicians who have at least 200 eligible cases.
  • Physicians must report on 60% of patients that qualify for each measure selected, regardless of payer, unless reporting via claims or the CMS Web Interface, where only Medicare Part B patients are included.

Cost  – 15%

  • No data submission is required.
  • CMS calculates cost using claims data.
  • Measures include Medicare Spending per Beneficiary (MSPB), Total per Capita Cost, and eight episode-based measures.
  • CMS is developing additional episode-based cost measures for use in future program years.

Promoting Interoperability (PI)* 25%

  • ECs must report on a set of required measures and are scored based on performance.
  • Failure to report any of the required measures will result in a score of zero for the entire performance category.
  • In the 2019 performance period, ECs must use 2015 Edition certified electronic health record technology (CEHRT) for the 90 days they selected to report the promoting interoperability performance category.

*This category was formerly called advancing care information (ACI).

Improvement Activities – 15%

  • Physicians 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.
  • 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).
  • Certified or recognized patient-centered medical homes (PCMH) will receive full credit.
  • Activities must be completed for at least 90 consecutive days.

MIPS Reporting Options

Last updated: February 2019

New: 2019 MIPS Playbook

Get the AAFP's newest guide to navigating the Merit-based Incentive Payment System (MIPS)..

Free for Members

 

More on the MIPS Performance Categories

Want to dig deeper into the performance categories associated with MIPS?