What is MIPS?
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:
- Improvement Activities,
- Promoting Interoperability, and
It’s worth noting, however, that according to the APTA, eligible PTs will only be scored in two categories in 2019: 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 2019 score will affect his or her 2021 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.
As of 2019, physical therapists, occupational therapists, and qualified speech-language pathologists are included in this program.
What are some definitions I need to know to understand MIPS?
There are several definitions—some new to MIPS in 2019, and some not—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, in which a clinician’s performance is evaluated.
Payment Year: The year that participants receive their payment for a performance year.
Small Practice: A practice that contains 15 or fewer MIPS-eligible clinicians.
Group: A selection of multiple MIPS-eligible clinicians who bill under a single TIN.
Virtual Group: A selection of solo practitioners and/or groups of ten or fewer participants who report as a group regardless of specialty or location.
Submission Type: The way in which a MIPS-eligible clinician, group, or third-party intermediary submits MIPS data to CMS for MIPS. For example, MIPS participants may submit via:
- Direct submission (i.e., registry),
- Log in and attest,
- Log in and upload,
- Medicare Part B claims, or
- The CMS Web Interface.
Collection Type: A method of collecting comparable quality measures that requires a certain level of data completion. Examples include:
- CMS Web Interface measures (for quality measures only)
- The CAHPS for MIPS survey measures
- Administrative claims measures
- Electronic Clinical Quality Measures (eCQMs)
- MIPS Clinical Quality Measures
- Qualified Clinical Data Registry (QCDR)
- Medicare Part B claims measures (for small practices only)
What is the MIPS determination period?
The MIPS determination period is the length of time over which a provider or group is evaluated to determine whether they qualify for MIPS and/or any special determinations within the program. Beginning with the 2021 payment year, the universal MIPS determination period will identify 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 of the determination period 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.
The first segment also includes a 30-day claims run-out, which grants individuals and groups an additional 30 days to submit claims after the conclusion of the 12 months. The second segment does not include a 30-day claims run-out, but instead includes quarterly snapshots “if technically feasible.”
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.
Learn everything PTs, OTs, and SLPs need to know about MIPS in 2019.
Am I eligible to participate in MIPS?
In 2019, a MIPS-eligible clinician must:
- be identified by a unique combination of a Tax Identification Number (TIN) and National Practitioner Identifier (NPI), and
- be one of the following providers:
- Physician assistant
- Nurse practitioner
- Clinical nurse specialist
- Certified registered nurse anethesist
- Physical therapist
- Occupational therapist
- Qualified speech-language pathologist
- Qualified audiologist
- Clinical psychologist
- Dietician or nutrition professional
- A group that includes clinicians
Providers and groups must also exceed the three low-volume threshold criteria 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 APMs.
After the conclusion of a determination period, providers may check their QPP participation status and MIPS eligibility using this participation lookup.
What is the low-volume threshold?
The low-volume threshold is a set of criteria put in place to exclude from MIPS participation those providers who have little-to-no interaction with Medicare beneficiaries (e.g., those in small practices and rural areas), thus reducing their administrative burden. The 2019 final rule states that if a provider or group meets at least one of the following criteria during the low-volume threshold determination period, then they are excluded from MIPS:
- Billed Medicare for $90,000 or fewer in Part B allowed charges;
- Provided care to 200 or fewer Medicare Part B beneficiaries; and/or
- Provided 200 or fewer covered professional services under the Physician Fee Schedule.
According to the final rule, 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 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.
CMS implemented this procedure to prevent providers who apply QDCs to their claims from accidentally opting into the program.
How do the four categories work?
Each category awards a certain number of points depending on its weight. If, for example, a MIPS-eligible clinician participated in all four categories, then that clinician could earn 45 MIPS points in Quality, 15 MIPS points in Improvement Activities, 25 MIPS points in Promoting Interoperability, and 15 MIPS points in Cost.
Each category uses a unique scoring system which—at the conclusion of the scoring process—is then converted into the appropriate number of MIPS points.
The Quality category—which essentially replaced PQRS—evaluates the quality of a provider’s or group’s care using established 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 the total MIPS score for PTs, OTs, and SLPs—and 45% for general participants—quality is the most influential category for a participant’s overall score.
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. Groups consisting of 16 or more eligible clinicians may earn an additional ten points for a measure titled “all-cause hospital readmissions,” giving them a category cap of 70 points.
Additionally, groups that are large enough to submit Quality measures through the CMS Web Interface may submit 11 measures, along with “all-cause hospital readmissions,” for a total cap of 120 category points.
According to the APTA, participants can lose points on each measure in one or more of the following ways:
- Poor performance;
- Submitted measure doesn’t have a benchmark;
- Submitted measure doesn’t have at least 20 cases; and
- Submitted measure doesn’t meet data completion requirement.
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. Benchmarks are organized into deciles that cover certain performance percent ranges. Each range corresponds with specific point accumulations.
Here’s an example from CMS:
“If a clinician submits performance data of 83% on a non-inverse measure, and the 5th decile begins at 72% and the 6th decile begins at 85%, then the clinician will receive between 5 and 5.9 points because 83% is in the 5th decile.”
In order to obtain all possible points in the Quality category, reported data must meet a certain level of completeness. (Satisfactory “completeness” is entirely dependent upon collection type.)
Individuals and groups who use QCDR measures, MIPS CQMs, and eCQMs to collect their quality measure information must report on 60% 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 60% of their Medicare Part B patients for the performance period.
Those who use the administrative claims measures collection type must report on 100% of their Medicare patients for the performance period. A group that uses the CMS Web Interface to submit its measures must follow these instructions: “populate data fields for the first 248 consecutively ranked and assigned Medicare beneficiaries in the order in which they appear in the group’s sample for each module/measure. If the pool of eligible assigned beneficiaries is less than 248, then the group would report on 100 percent of assigned beneficiaries.”
For a full breakdown of data completion requirements by collection type, refer to Table 34 on page 1,008 of the final rule.
If MIPS participants submit outcome or patient experience quality measures, then they will earn an additional two points per submitted measure.
If participants submit high-priority measures that meet the data completion standard and they have a “performance rate of greater than 0,” then they will receive one additional point per submitted measure. Groups that submit quality measures through the CMS Web Interface are not eligible for the high-priority bonus points.
MIPS-eligible clinicians may also earn a bonus point for each measure they submit via end-to-end electronic reporting. Quality bonus points are capped at 10% of the denominator of the total quality performance category. So, for example, a provider who can earn 60 total points can only earn six bonus points.
MIPS-eligible clinicians in small practices will earn six bonus points in the quality category if they include data on at least one quality measure.
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, refer to this CMS source.
MIPS Quality Measures for PTs and OTs
Currently, PTs and OTs have 11 measures they can report. The four primary measures are:
- Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up
- Documentation and Verification of Current Medications in the Medical Record
- Pain Assessment Prior to Initiation of Patient Treatment
- Functional Outcome Assessment
Additionally, there are seven Focus on Therapeutic Outcomes (FOTO) measures that qualify for MIPS submission. For a full list of the available quality measures for PTs and OTs, refer to Table B.29 on pages 2,290–2,292 of the final rule.
MIPS Quality Measures for SLPs
According to the American Speech-Language-Hearing Association (ASHA), SLPs have three measures they can report for the quality category in 2019:
- Tobacco Cessation/Screening
- Pain Assessment
- Medication Documentation
Meaningful Measures Initiative
Introduced in October 2017 as a subset of the Patients Over Paperwork initiative, the Meaningful Measures initiative was a collaborative effort between CMS and stakeholders to refine and improve the selection of Quality measures available for MIPS reporting.
In the final rule, CMS stated:
“The Meaningful Measures Initiative represents a new approach to quality measures that fosters operational efficiencies, and reduces cost associated with collection and reporting burden, while producing quality measurement that is more focused on meaningful outcomes.”
The Meaningful Measures framework is divided into 19 categories—each of which reflects “specific, overarching healthcare priorities.” All quality measures must now fall into one of these categories in order to be considered “meaningful” and thus, earn a spot as MIPS reporting option. The 19 categories are:
- Healthcare Associated Infections
- Preventable Healthcare Harm
- Care is Personalized and Aligned with Patient’s Goals
- End of Life Care According to Preferences
- Patient's Experience of Care Patient Reported Functional Outcomes
- Medication Management
- Admissions and Readmissions to Hospitals
- Transfer of Health Information and Interoperability
- Preventive Care
- Management of Chronic Conditions
- Prevention, Treatment, and Management of Mental Health
- Prevention and Treatment of Opioid and Substance Use Disorders
- Risk Adjusted Mortality
- Equity of Care
- Community Engagement
- Appropriate Use of Healthcare
- Patient Focused Episode of Care
- Risk Adjusted Total Cost of Care
After conducting evaluations using the Meaningful Measures framework, CMS eliminated 26 quality measures—and added eight new ones—for the 2019 performance year.
In 2019, individual MIPS-eligible clinicians may use eCQMs, MIPS CQMs, or QCDR measures to collect information during the performance year. The eligible individual may either submit his or her data directly, or log in and upload measures. If the individual works in a small practice, he or she may collect and submit measures for the quality category via Medicare Part B claims.
In 2019, MIPS-eligible groups may use eCQMs, MIPS CQMs, QCDR measures, the CAHPS for MIPS survey, or administrative claims measures to collect information for the performance year. Groups may either submit their reports directly or log in and upload their measures. If a group works out of a small practice, it may collect and submit measures for the quality category via Medicare Part B claims. If a group consists of 25-plus clinicians, it may use the CMS Web Interface to submit quality measures.
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 (IA)
Improvement Activities is the only MIPS category that isn’t derived from a previously-existing program. With a possible score of 40 points, the IA category is weighted at 15% of the total MIPS score for general participants—and 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 award ten and 20 points, respectively. From there, the activities are divided into nine subcategories:
- Care coordination,
- Patient safety and practice adjustment,
- Beneficiary engagement,
- Participation in APM,
- Achieving health equity,
- Integrating behavioral and mental health,
- Emergency preparedness and response,
- Expanded practice access, and
- Population management
Individuals and groups may report any relevant activity from any subcategory, but they must submit activities with one of the following combinations of weighting:
- Two high-weighted activities
- One high-weighted activity and two medium-weighted activities
- Four or more medium-weighted activities
The APTA took the CMS’s full list of Improvement Activities, identified which apply to PTs and OTs, and created a comprehensive list to help with IA reporting. The list includes nine “medium” activities and three “high” activities.
The Improvement Activities category is evaluated during a 90-day performance period, and each reported activity must meet the 90-day requirement. Essentially, the activity must have been performed for 90 consecutive days during the performance year.
This category allows for different weighting for:
- groups with 15 or fewer clinicians,
- 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.
To fulfill the requirements for this category, clinicians who qualify for this exception may submit one of the following combinations of activity weightings:
- One high-weighted activity
- Two medium-weighted activities
Individuals and groups have a few options when it comes to submitting Improvement Activities data for MIPS. First, MIPS participants may use a vendor and submit activities directly using a QCDR, a Qualified Registry, or an EHR system. Alternatively, participants may submit activities by logging onto the QPP website and attesting.
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.
There are no longer any bonus points available in this category.
Promoting Interoperability (PI)
The Promoting Interoperability (PI) category—formerly Advancing Care Information—has roots in the MU program and assesses how clinics use certified electronic health record technology (CEHRT) to engage patients. Essentially, PI determines whether a practice engages its patients by sharing treatment information like test results, visit summaries, and therapy plans.
For the 2019 year, this category will be weighted at 25% of a participant’s final MIPS score. Because this category does not apply to PTs, OTs, and SLPs in 2019, it will be reweighted to 0% for those clinicians.
Promoting Interoperability Scoring
The Promoting Interoperability category is evaluated during a 90-day (minimum) continuous performance period, during which a MIPS-eligible clinician can earn up to 100 points.
Points are assigned on a measure-by-measure basis, with point values varying based on performance or a yes/no submission response.
Each measure in the PI category falls under one of four objectives, each of which contains different maximum point assignments.
- e-Prescribing (10 points)
- Health Information Exchange (20 points)
- Provider to Patient Exchange (40 points)
- Public Health and Clinical Data Exchange (10 points)
MIPS-eligible clinicians who participate in Promoting Interoperability must report specific measures under every single objective. According to CMS, “failure to report any required measure, or reporting a ‘no’ response on a yes/no response measure, unless an exclusion is claimed will result in a Promoting Interoperability performance category score of zero.” For a list of all available PI measures, visit the QPP official website.
Clinicians may apply for a measure exclusion that—if approved—will reallocate all applicable points to other PI measures. Eight different measures allow for measure exclusions.
Individuals and groups can submit measures for the PI category in several ways. MIPS participants may use a vendor and submit activities directly using a QCDR, a Qualified Registry, or an EHR system. Alternatively, participants may report by logging into the QPP website and uploading their measures.
Before finalizing PI submissions, participating clinicians and groups must attest “that they have not knowingly and willfully limited or restricted the compatibility or interoperability of their certified electronic health record technology (CEHRT).” They must also attest to “having completed the actions included in the Security Risk Analysis measure” during the performance year.
The Promoting Interoperability submission deadline is uniform across the board. All MIPS-eligible clinicians must report before March 31 of the year following the performance year.
MIPS-eligible clinicians or groups can opt out of the PI category if they apply and qualify for a hardship exception. MIPS providers are only eligible for a hardship exception if they met one of the following criteria during an applicable performance period:
- Lacked sufficient Internet access (slow Internet does not count);
- Faced EHR or CDSM vendor issues; or
- Faced “ extreme or uncontrollable circumstances.”
If CMS approves a hardship application, the PI category is reweighted to 0% and the extra 25% of the MIPS score is reallocated to the Quality category. However, if a provider or a group chooses to report for the PI category even after submitting a hardship exception application, the application will be voided and no reweighting will occur.
MIPS-eligible providers may apply for a hardship exception here.
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 and weights the final score at 15%.
PTs, OTs, and SLPs are not included in this category in 2019, and it will be reweighted to 0% of their final score.
For the Cost category, CMS evaluates the Medicare claims from each participant using any relevant cost-based measure from the following list:
- Total Per Capita Cost (TPCC)
- Medicare Spending Per Beneficiary (MSPB)
- Elective Outpatient Percutaneous Coronary Intervention (PCI)
- Knee Arthroplasty
- Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Routine Cataract Removal with Intraocular Lense Implantation (IOL)
- Screening/Surveillance Colonoscopy
- Intracranial Hemorrhage or Cerebral Infarction
- Simple Pneumonia with Hospitalization
- ST-Elevation Myocardial Infarction (STEMI) with PCI
Measure performance determines the number of points a MIPS-eligible clinician receives in this category. Using the points obtained from those measures, CMS then calculates the overall cost score with the following formula:
Cost Achievement Points ÷ Available Points = Cost Category % Score
The Cost performance category score will be omitted—and the other MIPS categories reweighted—“if the eligible clinician is not attributed any Cost measures because of case minimum requirements or the lack of a benchmark.”
There are no measure submission requirements for the Cost category. CMS automatically pulls this information from the performance year’s administrative claims data.
There’s a five-point overall MIPS point bonus available to providers and groups who treat “medically complex patients.”
What are Advanced Alternative Payment Models (APMs)?
APMs—like MIPS—were designed to incentivise 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. If a provider or group wants to scout out APMs for the upcoming performance year, they may do so here.
How will my MIPS points affect my finances?
The performance threshold for 2019 is 30 MIPS points. This means a provider or group must score a minimum of 30 MIPS points during the 2019 performance period to avoid a negative payment adjustment on every covered professional service submitted to Medicare during 2021 payment year.
A score of exactly 30 MIPS points in the 2019 performance year will result in a neutral adjustment—meaning the participant won’t receive any payment adjustment, positive or negative, during the 2021 payment year.
MIPS participants who score between 29.99 and 7.51 points in the 2019 performance year will receive a negative payment adjustment that falls between -0.01% and -6.99%. Participants who score between 7.5 and 0 points will get slapped with a flat adjustment of -7% in the pertinent payment year.
On the other end of the spectrum, MIPS participants who score more than 30 points in the 2019 performance year will receive a positive adjustment between 0.01% and 7%. Participants who score 75 points or more will 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 2022 and gets a 2% bonus adjustment in 2024, that same score won’t necessarily earn him or her the same bonus the following year.
When will I find out my MIPS score?
CMS will notify MIPS participants of their scores in July following the performance year. Say, for example, you participate in MIPS in 2019. You will receive notification from Medicare in July 2020 with the breakdown of your MIPS score. If applicable, the subsequent payment adjustment then goes into effect on January 1, 2021.
How do I join a virtual group?
Before providers or a groups join or create a virtual group, they must first determine their eligibility—based on certain TIN size criteria—by contacting their local QPP Technical Assistance organization.
Once the technical assistance organization approves each prospective member of the virtual group, members must sign the formal written agreement already created by the virtual group. If members are forming a new virtual group, then they must compose their own formal written agreement that satisfies nine specific criteria. CMS does not require its own copy of the agreement at this time.
At that point, prospective virtual group members must then elect a virtual group representative from within their ranks. The virtual group representative must then email a request to CMS at MIPS_VirtualGroups@cms.hhs.gov by December 31 prior to the relevant performance year. That request must contain the following information.
- The TIN, legal business name, NPI, and name of each individual virtual group member (“For a TIN that is the Social Security Number (SSN) of a clinician, only include the last six digits of the SSN when submitting an election to CMS.”)
- The name of the virtual group representative, his or her TIN/practice affiliation, and his or her contact information
- An acknowledgement that the virtual group created a formal written agreement among its members
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.
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.
CMS is pushing providers to take advantage of voluntary reporting:
“We encourage clinicians who are not eligible to participate in MIPS to voluntarily report on applicable measures and activities for MIPS. The data received will not be used to assess performance for the purpose of the MIPS payment adjustment; however, these clinicians will have the opportunity to access feedback on their submitted MIPS data.”
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.
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