Despite the fact that earlier this year CMS sent confusing letters to numerous rehab therapy clinics about their participation status in the Merit-Based Incentive Payment System (MIPS), physical therapists, occupational therapists, and speech-language pathologists are still not eligible to officially participate in this quality reporting initiative. (You can double check your eligibility status by entering your NPI in the form here.) According to the APTA, though, “it's almost a given that PTs will be mandatorily included as early as 2019.” That means that while physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse practitioners are required to participate in MIPS during the ramp-up period before the program becomes more robust, PTs, OTs, and SLPs can choose to use this time to prepare—or not. Because we here at WebPT are all for preparation, here are some MIPS basics as well as some program updates from the 2018 Quality Payment Program Final Rule:

New Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Regular BannerNew Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Small Banner

What is MIPS?

The Merit-Based Incentive Payment System (MIPS) is a consolidation of Medicare’s Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Payment Modifier (VM) programs. It officially went into effect on January 1, 2017. According to CMS, providers who participate in MIPS “earn a payment adjustment based on evidence-based and practice-specific quality data.” In other words, each year, providers demonstrate that they “provided high quality, efficient care supported by technology by sending in information in the following categories”:

  1. Quality (which replaces PQRS);
  2. Improvement Activities (which is a new reporting component);
  3. Advancing Care Information (which replaces MU); and
  4. Cost (which replaces VM)

MIPS Scoring

And each category is weighted to make up 100 percentage points, as follows:

  • Quality: 50% in 2018 (down from 60% in 2017)
  • Improvement Activities: 15% in 2018 (same as 2017)
  • Advancing Care Information: 25% in 2018 (same as 2017)
  • Cost: 10% in 2018 (up from 0% in 2017)

In short, a provider’s final score will dictate the MIPS payment adjustment that will be applied to that provider’s Medicare Part B payments two calendar years later (i.e., the 2018 score dictates the 2020 adjustment, the 2019 score dictates the 2021 adjustment, and so on). Under MIPS, eligible providers have the option to participate individually or as a group under one Tax ID Number (TIN).

What’s new in the Final Rule?

In an effort to decrease clinician burden and improve provider success in the program, CMS announced several new MIPS policy changes for 2018, including:

  • Increasing the performance threshold to 15 points (up from 3 in 2017).
  • Adding up to five bonus points to providers’ final scores for treating complex patients.
  • Providing assistance to clinicians impacted by hurricanes Irma, Harvey, and Maria—as well as other natural disasters—by “automatically weighting [their] Quality, Advancing Care Information and Improvement Activities performance categories at 0% of the final score.”
  • Making "it easier for eligible clinicians to participate in select APMs [alternative payment models]...which may allow them to qualify for incentive payments.” (According to the APTA, providers would be wise not to limit their participation in “APMs to only Medicare-based programs.”)
  • Helping small practices by adding five bonus points to their final scores.

CMS is making an effort to help small practices.

In addition to affording small practices five bonus points as mentioned above, CMS is offering other “tailored flexibilities for groups of 15 or fewer clinicians” to help ensure successful participation in MIPS, including:

  • Allowing solo practitioners and small practices to “form or join a virtual group to participate with other practices.” (According to CMS, solo practitioners and groups of 10 or fewer eligible professionals can come together “virtually” to participate in MIPS together for a specific performance period.” Click here to download CMS’s virtual group toolkit.)
  • Giving three points to small clinics “for measures in the Quality performance category that don’t meet data completeness requirements.”
  • Requiring small practices to only complete two medium-weighted (or one high-weighted) Improvement Activities component(s) to earn the full score.
  • Offering a “hardship exception for the Advancing Care Information performance category for small practices.”
The minimum threshold for participation has increased.

Furthermore, according to WebPT’s in-house compliance resource, Betsy Hyder—who conducted an in-depth review of the MACRA Final Rule—CMS also increased the minimum thresholds for eligible provider participation. As explained in this document, in 2018, “eligible clinicians with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries” are excluded from participation in MIPS. In 2018, there is no opt-in option for providers who are excluded because they only meet one of the minimum criteria. For reference, Hyder says that “the minimums are measured from claims submitted in two consecutive 12-month periods (September 1, 2016, to August 31, 2017, and September 1, 2017, to August 31, 2018).” Providers who do not exceed the threshold during either period will be considered excluded.

Small practices may benefit from group reporting.

That means that, even if small rehab therapy practices were considered eligible providers for the coming year, many would still be participating in MIPS on a voluntary, rather than mandatory, basis—which means they wouldn’t be eligible to reap the financial benefits of the program. Hyder pointed out that individual providers and small practices who don’t meet the minimum threshold for participation on their own may be eligible for group reporting. It's one way small rehab therapy practices may be able to complete MIPS reporting once PTs, OTs, and SLPs become eligible participants in 2019—even if Medicare maintains its current patient volume and billing criteria.

Here are several more important pieces of MIPS info.

Hyder also noted several other important pieces of MIPS-related information that PTs, OTs, and SLPs should be aware of, including:

  • To report successfully in 2018, eligible providers must collect 12 months of Quality data and at least 90 days of consecutive data for Advancing Care Information and Improvement Activities. According to this document, CMS will continue to measure cost for 12 months.
  • To fulfill the Quality category requirements, eligible providers and groups must report on six measures and one outcome measure for at least 60% of beneficiaries whose claims were submitted and processed. CMS will award one point for each incomplete measure—unless the practice is small, in which case CMS will award three points.
  • Eligible providers who are not excluded from participation must earn 15 points from the combined categories in order to earn or avoid the positive or negative 5% payment adjustment in 2020. Providers or groups who score 70 points or more will earn an additional 0.5 to 10% scaled bonus.
  • CMS anticipates that facility-based providers will be able to report quality measurement data in 2019; however, they will not be able to do so in 2018.
  • No specialty measure group for rehab therapy was added to the measure set for 2018.

The Final Rule lays the foundation for future years.

According to Hyder, many of CMS’s changes to MIPS in the Final Rule are intended to lay the foundation for its future. And CMS has acknowledged that it expects the program to “evolve over multiple years.” The agency believes that “the groundwork has been laid for expansion toward an innovative, patient-centered...health system that is both outcome focused and resource effective.” That being said, CMS has “heard challenges and concerns from stakeholders,” which is why it plans to continue:

  • “Going slow while preparing clinicians for full implementation in year three.”
  • “Providing more flexibility to help reduce your burden.”
  • “Offering new incentives for participation.”

CMS is also continuing to offer its free, hands-on technical assistance program to improve participation success.


According to the APTA, “As health care moves to outcomes-based payment, it will be critical for PTs [as well as OTs and SLPs] to have access to real-time clinical data to understand how they perform, identify areas to improve quality, and manage patient populations.” On the other hand, “without data...therapists will be unable to receive future incentive payments.” That’s why WebPT’s president, Heidi Jannenga, believes that one of the best ways you can prepare for the inevitable shift to quality reporting is by continuing to build the profession’s “data stores by committing to collecting meaningful outcomes data.” To learn more about WebPT’s integrated outcomes tracking program, click here. And for a full discussion of the regulatory changes that will impact PTs, OTs, and SLPs in 2018 and beyond, be sure to check out our free Regulatory Roundup webinar.

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