Physical Therapists’ Guide to MIPS

Introduction

The Merit-Based Incentive Payment System (MIPS) is one of two tracks in the Quality Payment Program (QPP) currently administered by the Centers for Medicare and Medicaid Services (CMS). A consolidation of several legacy programs—the Physician Quality Reporting System (PQRS), the Meaningful Use (MU) program, and the Value-Based Modifier (VM) program—MIPS is a streamlined, one-stop shop for CMS to measure quality and provide financial incentives for eligible clinicians to improve their level of care.

MIPS assesses the merit of a provider’s services across four categories:

1. Quality,
2. Improvement Activities,
3. Promoting Interoperability, and
4. Cost.

It’s worth noting, however, that per the 2021 final rule, eligible rehab therapists will only be scored in two categories in 2021: Quality and Improvement Activities. At the end of each calendar year, eligible providers submit their relevant data to CMS and receive a MIPS score—ranging from 0–100 points—before the start of the payment year. That score determines the capped adjustment (either positive or negative) the clinician receives from Medicare two years later. For example, a provider’s 2021 score will affect his or her 2023 adjustment.

A Brief History of MIPS

In April 2015, Congress voted to overhaul the Sustainable Growth Rate (SGR) formula and implement a new quality reporting and incentive system as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). From MACRA came the QPP, which brought about both MIPS and Advanced Alternative Payment Models (APMs). MIPS reporting began in 2017, with clinicians who participated in the first reporting year seeing their first batch of adjustments in 2019.

Physical therapists, occupational therapists, and qualified speech-language pathologists were included in this program as of 2019.

What are some definitions I need to know to understand MIPS?

There are several definitions that are pivotal to understanding the ins and outs of the MIPS program.

Performance Year/Period: The calendar year, from January 1 to December 31, during which a MIPS participant’s performance is evaluated
Payment Year: The year that participants receive their payment adjustment for a performance year
Small Practice: A practice that contains 15 or fewer MIPS-eligible clinicians
Group: A selection of two or more clinicians with individual NPIs (one of which is MIPS-eligible) who bill under a single TIN
Virtual Group: A selection of more than one solo practitioner and/or groups of ten or fewer participants who report as a group regardless of specialty or location
Collection Type: A method of collecting comparable quality measures to certain levels of data completeness

What is the MIPS determination period?

The MIPS determination period is the length of time during which CMS evaluates a provider or group to determine whether they qualify for MIPS and/or any special status. It identifies participants who don’t exceed the low-volume threshold—as well as MIPS-eligible clinicians who may have different participation criteria because they are non-patient facing, hospital-based, ambulatory surgical center (ASC)-based, or in a small practice.

The MIPS determination period spans a 24-month time period that is split into two separate 12-month segments. The first 12-month segment begins on October 1 two years prior to the performance year and runs through September 30 of the year prior to the performance year. The second 12-month segment runs from October 1 of the year prior to the performance year to September 30 of the applicable performance year.

Here’s a rundown of the determination periods for the 2021 and 2022 performance years:

Performance Year	First Determination Segment	Second Determination Segment
2021	October 1, 2019–September 30, 2020	October 1, 2020–September 30, 2021
2022	October 1, 2020–September 30, 2021	October 1, 2021–September 30, 2022

If a MIPS participant does not exceed the low-volume threshold or is identified as non-patient facing, hospital-based, or ASC-based during either of the 12-month segments, the participant will be excluded from MIPS or classified as such for the applicable performance year.

Am I eligible to participate in MIPS?

A MIPS-eligible clinician must:

1. be identified by a unique combination of a Tax Identification Number (TIN) and National Practitioner Identifier (NPI), and
2. be one of the following providers:
   • Physical therapist 
   • Occupational therapist
   • Qualified speech-language pathologist
   • Qualified audiologist
   • Chiropractor
   • Clinical psychologist
   • Registered dietician or nutrition professional
   • Physician
   • Osteopathic practitioner
   • Physician assistant
   • Nurse practitioner
   • Clinical nurse specialist
   • Certified registered nurse anesthetist

Providers and groups must also exceed the three low-volume threshold criteria during both determination periods in order to be eligible for MIPS participation.

Based on these conditions, providers in facility-based outpatient therapy and skilled nursing facility (SNF) settings are excluded from MIPS eligibility, because claims for these settings typically only contain a facility NPI. Providers and groups are also excluded from MIPS if they enrolled in Medicare for the first time during the performance period, or if they participated significantly in Advanced APMs.

After the conclusion of a determination period, providers may check their QPP participation status and MIPS eligibility using this participation lookup tool.

Do I have to participate if I was impacted by COVID-19?

As a result of the COVID-19 pandemic, CMS updated its Extreme and Uncontrollable Circumstances application for the 2021 performance year in order to allow providers to request to opt out of some (or all) of the MIPS program. Please note, though, that if you submit any category data for the 2021 performance year it will override this application and you will receive a score.

Submission Process

MIPS participants can submit an Extreme and Uncontrollable Circumstances Application through the QPP website (qpp.cms.gov) by following these instructions from CMS: 

1. Register for a HARP account (i.e., an account through the QPP) if you don’t have one. 
2. Sign in to the QPP website.
3. Select “Exceptions Applications” in the navigation bar on the left side of the page.
4. Select “Add New Exception.”
5. Select “Extreme and Uncontrollable Circumstances Exception.”
6. Complete and submit the application.

What’s the difference between reporting as an individual and reporting as a group?

If a MIPS-eligible clinician decides to report as an individual (the default option), he or she will be evaluated and scored based on his or her performance only. The individual will be the only clinician to receive an adjustment based on his or her unique score.  

If a MIPS-eligible clinician has reassigned his or her Medicare billing rights to a single TIN, then he or she can elect to report as a group along with one or more other clinicians who bill under the same TIN. The members of the group will work together to report for MIPS, and CMS will evaluate and score the group’s performance as a whole. Every member of the group will receive the same adjustment based on the group’s overall score. 

Keep in mind that MIPS eligibility is determined on an individual basis, which means that a group will never be required to participate. However, if a couple of clinicians choose to participate as a group, then all the individuals at that clinic are required to participate and will receive the same score and payment adjustment.

How do I join a virtual group?

MIPS-eligible clinicians and small groups also have the opportunity to create and report as a virtual group. Virtual groups are not bound by location or specialty—and all members work together to report for MIPS. All members also receive the same score and performance adjustment.

Before providers or groups create a virtual group, they must first individually determine their eligibility—based on certain TIN size criteria—by contacting their local QPP technical assistance provider. Once each prospective member of the virtual group has been approved by a technical assistance provider, then the virtual group must: 

• Prepare for the upcoming reporting period; 
• Pick an official representative who will communicate with CMS; 
• Draft and sign a formal written agreement that meets CMS’s criteria; and 
• Email the virtual group election request to MIPS_VirtualGroups@cms.hhs.gov before January 1 of the reporting year.

If there are any changes to a virtual group after it receives CMS approval—but before the start of the performance year (e.g., a virtual group member leaves or a TIN changes)—the virtual group representative must notify QPP of the change. Changes cannot be applied to a performance year during its duration.

Do I qualify for a special status?

Some providers—and groups—qualify for a special MIPS program status, which generally means that they receive program modifications to reduce the burden of participation. For example, small practices are eligible for a bonus in the quality category and double points in the improvement activities category. Here are the special statuses:

Status	Qualifications	MIPS Modification
Small Practice	When a practice contains 15 or fewer MIPS-eligible clinicians	Eligible for six bonus points in the Quality categoryWill earn double points in the Improvement Activities category
Health Professional Shortage Area (HPSA)	When a MIPS participant practices in a government-declared HPSA	Will earn double points in the Improvement Activities category
Rural	When a MIPS participant practices in a rural ZIP code as specified by the Federal Office of Rural Health Policy	Will earn double points in the Improvement Activities category
Ambulatory Surgery Center (ASC)-Based	When a participating MIPS clinician furnishes at least 75% of covered care in a site identified by POS code 24	Automatically excused from the Promoting Interoperability category
Hospital-Based	When a MIPS participant furnishes at least 75% of covered care in a hospital	Automatically excused from the Promoting Interoperability category
Non-Patient Facing	When a MIPS participant conducts 100 or fewer Medicare Part B “patient-facing encounters”	Will earn double points in the Improvement Activities categoryAutomatically excused from the Promoting Interoperability category

What is the low-volume threshold?

The low-volume threshold is a set of criteria that excuses providers who have little-to-no interaction with Medicare beneficiaries from participating in MIPS. If a provider or group does not meet all three of the following criteria during both determination periods, then they are not required to participate in MIPS: 

• Billed Medicare for more than $90,000 in Part B allowed charges; 
• Provided care to more than 200 Medicare Part B beneficiaries; and
• Provided 200 or more covered professional services under the Physician Fee Schedule.

According to CMS, clinicians may determine what counts as a professional service by “calculating one professional claim line with positive allowed charges.”

At the end of the day, however, excluded providers and groups still have the opportunity to opt in to MIPS so long as they exceed one or two of the low-volume threshold criteria.

How do I opt in to MIPS?

MIPS-eligible clinicians or groups who exceed one or two of the low-volume threshold criteria—but not all three—are permitted to opt in to the MIPS program. To do so, eligible clinicians and groups must log into their account on the Quality Payment Program website and manually mark a selection indicating that they wish to opt in. Please note that if you do not meet or exceed any of the low-volume threshold criteria, then you may not opt in to MIPS as an individual.

What is voluntary reporting?

Clinicians and groups who are not currently MIPS-eligible may choose to voluntarily submit data to Medicare. Even though voluntary submissions won’t trigger a positive or a negative payment adjustment, they will earn category-specific feedback from CMS. Voluntary submitters can then review that information and prepare for future program inclusion.

To voluntarily report MIPS data, interested parties must log into their account on the Quality Payment Program website and manually mark an option indicating they wish to voluntarily report.

How do the categories work?

Each category awards a certain number of points depending on its weight. At the conclusion of the scoring process, the points in each category are converted into the appropriate number of MIPS points.

Quality

The Quality category—which essentially replaced PQRS—evaluates the quality of a provider’s or group’s care using performance measures. Participants select the performance measures most applicable to the care they provide from a CMS-approved list and submit them for evaluation at the conclusion of the performance year. Weighted at 85% of a PT’s, OT’s, or SLP’s total MIPS score, quality is the most important category that rehab therapists must report.

Quality Scoring

Each measure is worth a maximum of ten points. Although MIPS-eligible clinicians may submit more than six measures, CMS only counts the six highest-scoring submissions, creating a category point cap of 60 points.

According to the APTA, participants can lose points on each measure in one or more of the following ways:

1. Poor performance;
2. Submitted measure doesn’t have a benchmark;
3. Submitted measure doesn’t have at least 20 cases; and
4. Submitted measure doesn’t meet data completion requirement.

Benchmarks

Benchmarks allow CMS to evaluate and score quality measures on a national level. The national benchmarks for each quality measure differ based on collection type and previously collected “historical data” from PQRS and CAHPS surveys. These benchmarks determine how many points—on a scale of three to ten—a MIPS-eligible clinician receives for each reported measure.

Data Completion

In order to obtain all possible points in the Quality category, reported data must meet a certain level of completeness—which varies based on collection type.

Individuals and groups who use QCDR measures, MIPS CQMs, and eCQMs to collect their quality measure information must report on 70% of all patients, regardless of payer, for the performance period. Those who use Medicare Part B claims to collect and submit their measures must report on 70% of their Medicare Part B patients only for the performance period. 

Quality Measures

MIPS participants must submit data for at least six quality measures—one of which must be an outcome measure. However, if an individual or group does not have an applicable outcome measure, then the participant must instead report an additional high-priority measure.

In the case that a MIPS participant has fewer than six measures applicable, the participant must submit every applicable measure. To determine which quality measures are best-suited to your specific practice, review CMS’s list of quality measures.

MIPS Quality Measures for PTs and OTs

In 2021, the PT and OT specialty measure set contains 22 different measures. The 15 process measures are:  

• 126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
• 127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
• 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
• 130: Documentation of Current Medications in the Medical Record
• 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
• 154: Falls: Risk Assessment
• 155: Falls: Plan of Care
• 181: Elder Maltreatment Screen and Follow-Up Plan
• 182: Functional Outcome Assessment
• 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
• 281: Dementia: Cognitive Assessment
• 283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
• 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
• 288: Dementia: Education and Support of Caregivers for Patients with Dementia
• 318: Falls: Screening for Future Fall Risk

Additionally, PTs and OTs may report seven different Focus on Therapeutic Outcomes (FOTO) measures: measures 217–222 and measure 478.

MIPS Quality Measures for SLPs

In 2021, the SLP specialty measure set contains five different quality measures:

• 130: Documentation of Current Medications in the Medical Record
• 134: Preventative Care and Screening: Screening for Depression and Follow-Up Plan
• 181: Elder Maltreatment Screen and Follow-Up Plan
• 182: Functional Outcome Assessment
• 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Submission Deadline

Submission deadlines vary slightly depending on what collection and/or submission types a MIPS participant uses. Generally, a MIPS-eligible clinician must submit measures before March 31 of the year following the performance year.

However, for those who submit via claims, the claims must be processed “no later than 60 days following the close of the performance period.” Groups that report using the CMS Web Interface must submit all data during an eight-week period following the performance year. That eight-week reporting period must start and end between January 2 and March 31.

Improvement Activities

Improvement Activities is the only MIPS category that isn’t derived from a previously-existing program. With 40 available points, this category is weighted at 15% of the total MIPS score for general participants—as well as for PTs, OTs, and SLPs. This category evaluates the ways in which clinicians and groups work to improve their practice as a whole over an extended period of time (e.g., by enhancing care coordination, expanding patient access to care, and improving patient-clinician decision-making).

To report for this category, participating clinicians must select from a list of more than 100 available activities in the CMS Improvement Activities Inventory.

Improvement Activities Scoring

Improvement Activities are classified as either “medium” or “high” depending on the demands of the activity, and they award ten and 20 points, respectively. Individuals and groups may report any relevant activity from any subcategory, but they must submit activities with one of the following combinations of weighting: 

1. Two high-weighted activities,
2. One high-weighted activity and two medium-weighted activities, or
3. Four medium-weighted activities.

To successfully complete the Improvement Activities category, individual MIPS participants must perform each of their chosen activities for a consecutive 90-day period at some point during the performance year. At least 50% of the NPIs that report as a group must complete these activities in order for the full group to receive credit.   

Category Exceptions

This category allows for different weighting for:

• clinicians who work in a small practice,
• non-patient facing clinicians, and/or
• clinicians who are located in rural areas or Health Professional Shortage Areas (HPSAs).

In these cases, medium-weighted activities are worth 20 points, and high-weighted activities are worth 40 points.

Submission Deadline

The Improvement Activities submission deadline is identical for all collection and submission types. All MIPS-eligible clinicians must submit their activities before March 31 of the year following the performance year.

Promoting Interoperability and Cost

The Promoting Interoperability category—formerly known as Advancing Care Information—has roots in the MU program and assesses how clinics use certified electronic health record technology (CEHRT) to engage patients. Essentially, this category determines whether a practice engages its patients by sharing treatment information like test results, visit summaries, and therapy plans.

The Cost category—originally derived from the Value-Based Modifier program—measures the cost of a provider’s care either over the course of the year or during a patient’s hospital stay. CMS scores this category based on claims submitted throughout a performance year.

PTs, OTs, and SLPs are not required to report for either of these categories in 2021—and they will not count toward therapists’ final MIPS scores.

When will I find out my MIPS score?

CMS notifies MIPS participants of their scores in the first July that follows the performance year. For example, if you participate in MIPS in 2021, then you will receive a notification from Medicare in July 2022 that contains the breakdown of your MIPS score. If applicable, the subsequent payment adjustment will take effect on January 1, 2023.

How will my MIPS score affect my finances?

The 2021 performance threshold is 60 MIPS points. That means a provider or group must score a minimum of 60 overall MIPS points during the 2021 performance period to avoid a negative payment adjustment on every covered professional service submitted to Medicare during the 2023 payment year. 

A score of exactly 60 MIPS points in the 2021 performance year will result in a neutral adjustment—meaning the participant won’t receive any payment adjustment, positive or negative, during the 2023 payment year. 

MIPS participants who score 15.01 to 59.99 points during the 2021 performance year will receive a negative payment adjustment that falls between -0.01% and -8.99%. Participants who score 0 to 11.25 points will receive a flat -9% adjustment in 2023. 

On the other end of the spectrum, MIPS participants who score more than 60 points in 2021 will receive a positive adjustment between 0.01% and 9%. Participants who score 85 points or more will also be eligible to receive an exceptional performance bonus, which will be—at minimum—an additional +0.5% adjustment. 

Because CMS only has a limited sum of $500 million to divvy up among participants who earn the exceptional performance bonus, the bonus adjustment will fluctuate annually depending upon the performance pool as a whole. So, if a provider earns 95 MIPS points in 2021 and gets a 2% bonus adjustment in 2023, that same score won’t necessarily earn him or her the same bonus the following year.

Previous Program Results

According to CMS’s own data, clinicians who participate in MIPS generally earn a positive adjustment. But, because such a large majority of participants score well, there’s less money available to fund these positive performance adjustments. As such, the maximum recorded performance bonuses are significantly lower than what is potentially allowed by the program. Take a look at how previous MIPS participants have fared so far.   

Performance Year	Number of Participants	Percentage of Participants Who Earned a Positive Adjustment	Maximum Recorded Adjustment (Including the Exceptional Performance Bonus)
2017	1,057,824	93%	1.88%
2018	889,995	98%	1.68%
2019	954,604	96%	1.79%

What are Advanced Alternative Payment Models (APMs)?

Advanced APMs—like MIPS—were designed to incentivize providers and groups to improve the quality and cost of their care. Providers and groups may choose to participate in a handful of different APMs, some of which apply only to specific populations, care episodes, or clinical conditions.

Advanced APM participants may earn a 5% lump-sum incentive for hitting certain thresholds—though those thresholds are dependent upon the individual APM program. Those who meet the pertinent thresholds are excluded from MIPS for the year.

However, if a provider or group participates in a “MIPS APM” program, the participant will not necessarily be excluded from MIPS. These programs are designed to work in conjunction with MIPS in the case that a participant is considered MIPS-eligible. In some cases, a MIPS APM program might even require participants to participate in MIPS—but replace MIPS scoring methods with its own.

Interested parties must apply to participate in an APM between January 1 and April 1 of the year prior to the performance year.

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