Since the launch of the Quality Payment Program (QPP) in 2017, clinicians have struggled to keep up with the ever-evolving Merit-based Incentive Payment System (MIPS). Many clinicians are hoping if they wait long enough, CMS will discontinue the program altogether. But with QPP being written into the MACRA law and leading the transition from fee-for-service payments to the value-based care model, the MIPS program will continue to grow and evolve every year. The best course for clinicians to protect their revenue and reputation is to not only embrace MIPS but excel in their reporting efforts.
For the 2024 performance year, a clinician must earn 75 out of the possible 100 MIPS points to avoid a penalty. MIPS final scores will determine if the payment adjustment applied to your Medicare Part B-covered professional services is negative, neutral, or positive. The maximum penalty for not participating in MIPS is 9%, which equates to a $9,000 per clinician reimbursement reduction for every $100,000 billed to Medicare. However, according to CMS’ most recent reporting statistics in 2021, only 3% of all MIPS eligible clinicians received a negative payment adjustment which means most MIPS eligible clinicians are reporting at some level. The highest positive adjustment received for the 2021 reporting year was 2.34%, but any revenue boost is better than revenue loss.
Participation and Eligibility
Participation options refers to the levels at which data can be collected and submitted to CMS for MIPS. The two most common participation levels are individual or group reporting. An individual is defined as a single clinician, identified by their individual National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN). Individual clinicians report measures and activities based on their individual performance. CMS will assess performance across all performance categories at the individual level. If you only participate as an individual, your payment adjustment will be based on your individual final score from the MIPS performance categories.
To report as a group, a practice submits performance data on behalf of all clinicians billing under the TIN. If a clinician is MIPS eligible at the group level only, the practice can participate in MIPS as a group but is not required to do so. If the practice chooses to participate as a group, the MIPS eligible clinicians who aren’t eligible as individuals, but are eligible at the Group level, will be included in MIPS and receive a payment adjustment.
A clinician’s eligibility status is based on their NPI/TIN combination and whether they chose to report as an individual or group. Clinicians must meet a minimum low-volume threshold based on three aspects of covered Medicare Part B services – allowed charges, number of patients receiving covered professional services, and the number of covered services provided. To meet the low volume thresholds for 2024 and be required to report MIPS, clinicians must bill more than $90,000 for Medicare Part B covered professional services, see more than 200 Medicare Part B patients, and provide more than 200 covered professional services to Medicare Part B patients. If any of these thresholds are not met, the clinician or group are not required to report MIPS for that performance year.
Not all clinician types are MIPS eligible. If you’re not one of the clinician types listed below, you’re excluded from reporting and the MIPS payment adjustment:
- Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
- Osteopathic practitioners
- Chiropractors
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Physical therapists
- Occupational therapists
- Clinical psychologists
- Qualified speech-language pathologists
- Qualified audiologists
- Registered dietitians or nutrition professionals
- Clinical social workers
- Certified nurse midwives
CMS reviews past and current Medicare Part B claims and enrollment data for clinicians and practices twice for each performance year. Each review, or “segment,” analyzes a 12-month period. Analysis of data from the first segment is released as preliminary eligibility. Analysis of data from the second segment is reconciled with the first segment and released as the final eligibility determination. Clinicians can verify their MIPS eligibility using the QPP Participation Status tool using an individual NPI. Clinicians and practices generally must exceed the low-volume threshold during both segments of the MIPS Determination Period to be eligible for MIPS.
Special Statuses
QPP automatically assigns special statuses to MIPS eligible clinicians who meet certain criteria therefore affecting their reporting requirements. Special statuses can include ASC, hospital, or facility-based clinicians, non-patient facing clinicians, small practices (15 or fewer MIPS eligible clinicians), and those in a HPSA or rural area. More information on each special status and its impact on scoring and reporting circumstances can be found here.
Reporting Requirements
Once clinicians have determined their eligibility and participation option, they can select and perform measures and activities. There are four performance categories under MIPS: Quality, Performing Interoperability, Improvement Activities, and Cost. Each category has a weight of your overall MIPS score but remember these weightings can change based on special statuses.
Quality Category
The Quality category is worth 30% of your overall MIPS composite score and measures health care processes, outcomes, and patient experiences of care. Requirements and measures change every year, so it’s important to stay updated on the changes released each year in the Final Rule. Quality reporting data must be collected for every claim, for every payer from January 1st through December 31st of the reporting year. CMS does not allow “cherry picking” or hand selecting of patients for reporting.
Data can be collected through five different methods: Electronic Clinical Quality Measures (eCQMs), MIPS Clinical Quality Measures (CQMs), Qualified Clinical Data Registry (QCDR) Measures, Medicare Part B Claims Measures, and The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey. Each collection method represents a way to aggregate data from your EHR, billing system, or through a third-party vendor. Some methods require more manual data aggregation while others can pull data from an existing location. CMS and third-party vendors cannot dictate your collection method and each method has its own measures so clinicians should make sure they’re accessing the correct measures for their reporting method.
Participants need to submit collected data for at least six quality measures including – one outcome measure; or high priority measure in the absence of an applicable outcome measure; or a complete specialty measure set. Performance data must be submitted for at least 75% of the denominator eligible cases for each quality measure, which represents data completeness (this number has increased from 70% in 2023). You can report measures through different collection types to fulfill your six-measure requirement, however you cannot mix collection types on a single measure. If you choose to submit data for a specialty measure set, you must submit data on at least six quality measures within that set. If the measure set contains fewer than six quality measures, you should submit data for each quality measure in the set.
Quality measures are scored using CMS benchmarks. When you submit measures for the MIPS quality performance category, your performance on each measure is assessed against its benchmark to determine how many points the measure earns. Benchmarks are established for each collection type and are based on historical data from submissions to that collection type. For example, a measure reported as an eCQM will be compared to a different benchmark than the same measure reported as a MIPS CQM. If a quality measure or collection type doesn’t have a historical benchmark, CMS will attempt to calculate benchmarks based on data submitted for the current performance period. New last year, if no historical benchmark exists and no performance period benchmark can be calculated, then the measure will receive zero points. Exceptions to this rule are:
- New measures in their first year in the program are subject to a 7-point scoring floor provided data completeness requirements are met
- New measures in their second year in the program are subject to a 5-point scoring floor provided data completeness requirements are met
- Small practices will continue to receive 3 points for measures without a benchmark, even if data completeness and case minimum requirements aren’t met
Promoting Interoperability (PI) Category
The Promoting Interoperability performance category promotes patient engagement and electronic exchange of information using certified electronic health record technology (CEHRT) and is weighted at 25% of your MIPS composite score. An important change to PI reporting in 2024 – measures must be reported for consecutive 180-day period during the reporting year. Clinicians who report PI must use a CEHRT that meets ONC certification criteria (45 CFR 170.315). The CEHRT must be in place by the first day of the performance period, but only needs to be certified by the last day of the performance period. As in previous years, certain clinician types and special statuses will automatically have their PI category reweighted. Also important in 2024, the only clinician type that qualifies for automatic reweighting for PI is clinical social workers. All other eligible clinicians are therefore required to report PI data. There are instances where clinicians can submit a MIPS Promoting Interoperability Performance Category Hardship Exception application. Review the exception rules to see if it may apply to your circumstances.
Clinicians should review the PI category requirements as soon as possible. While most measures will be a simple yes/no attestation or numerators/denominators pulled from your EHR, some measures like the Security Risk Analysis require additional work. Remember, you must report all PI measures or you’ll receive zero points in this category. Some measures have exclusions, which can be claimed if they don’t apply to your practice. If claiming an exclusion, that measure’s points are reweighted to another PI measure.
Improvement Activities (IA) Category
Improvement Activities are worth 15% of your MIPS composite score and can be a relatively painless way to earn additional points for your final score. Activities have a minimum of a continuous 90-day performance period for 2024 unless otherwise stated in the activity description. Each activity must be performed in 2024, but multiple activities don’t have to be performed during the same 90-day period. There are 40 maximum points in this category and activities are either medium- or high-weighted. For most clinicians, medium-weighted measures earn 10 points and high-weighted earn 20 points each (unless you have a special status, then those points are doubled). There are some caveats to reporting these measures so read through the specifications – some have limitations on how many years they can be reported, some require a longer reporting period than 90 days, and if reporting as a group, at least 50% of clinicians in a group must report the same activity. When you attest to an activity, you don’t need to submit your documentation, but you will have to keep it for six years in case you’re audited by CMS.
Cost Category
The Cost category is worth 25% of your MIPS composite score, however it is the only category that doesn’t require work on the part of the clinician or group. CMS uses Medicare administrative claims data to calculate cost measure performance. Participants are evaluated and scored on each cost measure for which you meet or exceed the established case minimum. CMS determines measure achievement points by comparing performance on a measure to a performance period benchmark. Cost measure benchmarks use performance data from the performance period, rather than historical data. You must meet the established case minimum for and be scored on at least one measure to receive a cost performance category score. If not, this category can be reweighted to one or more other performance categories.
Achieving MIPS Success Now and Later
Achieving success in MIPS seems like a daunting task, but with preparedness and effort, clinicians can find themselves on the positive end of QPP. Start off the reporting year strong by scheduling time to review your quality reporting data regularly. If you work with a third-party vendor, touch base with them to see if they have feedback on how to improve your scores. Don’t neglect Improvement Activities and Promoting Interoperability categories as both can boost your overall composite score to meet and exceed the minimum threshold. And lastly, prepare for upcoming changes to performance year 2025 requirements for reporting of eCQMs. Moving forward, only CERHT vendors can calculate and submit eCQMs on behalf of the eligible clinician or group. You may need to reconsider your third-party vendor if this is your collection method.
For more information on MIPS reporting, visit https://www.alphaii.com/solutions/cehrt-based-quality-reporting.
