MIPS FAQ

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. MACRA created the Quality Payment Program (QPP) that transitions Medicare from a fee-for-service payment model toward value-based reimbursement. There are two tracks under QPP – the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

The four performance categories for traditional MIPS reporting in 2023 and their percentage of overall MIPS score are:

• Quality – 30%
• Promoting Interoperability – 25%
• Improvement Activities – 15%
• Cost – 30%

Actual category weighting will depend on category applicability and other factors, like special statuses. 

CMS oversees the QPP. Their site for program updates is qpp.cms.gov. From that page, the Resource Library contains general and regulatory reference materials such as fact sheets, measure specifications, guides, and more.

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.

Clinicians have the option to report MIPS data as an individual or group. This is known as the participation option. 

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 will collect and report measures and activities based on their individual performance. CMS will assess your 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.

MIPS eligibility is based on a clinicians NPI/TIN combination. CMS has a QPP Participation Status tool available on their website. With this tool, you can use your individual NPI to view:
•    Eligibility as an individual and group (with each associated TIN)
•    Eligibility for each MIPS determination period
•    Low-volume thresholds and amounts
•    Special statuses

If a practice decides to report as a group under their TIN, they must report on every MIPS eligible clinician associated with that TIN. If reporting data is not sent for any MIPS eligible clinician in the TIN, the maximum scoring adjustment will be applied.

No, individual level submissions and group level submissions will not be combined into a single final score. The only exception are Medicare Part B claims, which are always reported at the individual level and available only to small practices as a reporting option. CMS will aggregate this quality data to the group level if the small practice also submitted data for another performance category at the group level.

There are circumstances where a MIPS eligible clinician can be exempt from a specific reporting category. If that happens, most often the weighting from the exempt category is reweighted to the Quality Reporting category.

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 and circumstances can be found here.

A collection type refers to a set of quality measures that have comparable specifications and data completeness requirements. For example, eCQMs and MIPS CQMs are both collection types.

No, patient data for all payers must be submitted for the entire MIPS performance year. To withhold information is considered cherry-picking and not allowed under the MIPS program.

Yes, if the clinician billed under your TIN in the performance year, you must include their data for MIPS reporting. The same would apply if you had a clinician leave your practice during the performance year.

Data completeness means MIPS eligible clinicians must report performance data for at least 70% of the denominator eligible cases for each quality measure. If you have not met this threshold, you will not receive points for that measure (unless you are a small practice).a

Yes, you can use your most advantageous method to report different performance categories. Within the quality category, you can submit measures from different collection types to fulfill the requirement to report data for at least 6 quality measures. For example, you can report using eCQMs and CQMs to achieve the best quality score. However, CMS will not aggregate different reporting methods for the same measure. 

Quality measure benchmarks are the point of comparison CMS uses to score the measures you submit. 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 for this reporting year, if no historical benchmark exists and no performance period benchmark can be calculated, then the measure will receive 0 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

MIPS Value Pathways (MVPs) are the newest reporting option to fulfill MIPS reporting requirements starting in 2023. It is separate from traditional MIPS and is a new, voluntary way to meet MIPS reporting requirements. Each MVP includes a subset of measures and activities that are related to a specialty or medical condition to offer more meaningful participation in MIPS. CMS plans to sunset traditional MIPS in the future, at which point MVPs will become mandatory unless the clinician is eligible to report the APM Performance Pathway (APP).

The benefits of transitioning to MVPs now:

• Specialized assessment of quality of care
• Streamlined, reduced set of measures and improvement activities
• Familiarity with MVP reporting and the future of the MIPS program while the risk is low

You can only register for an MVP during the MVP Registration Window, which is April 3 through November 30, 2023 for the current performance year. 

Learn more about MVPs here.