What is MIPS?

June 7, 2019

The Merit-based Incentive Payment System (MIPS) is a Quality Payment Program (QPP) developed by CMS to get providers to focus on performance improvement by paying bonuses to providers who perform well in certain measures. There are four domains that clinicians report on with each accounting for a percentage of your overall score: Quality, Improvement Activities, Promoting Interoperability and Cost. MIPS was designed to coordinate and align the Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM). Payment adjustment is based on a cumulative score calculated from the data submitted.

Who must participate?

Eligibility requirements can be found on the QPP how MIPS eligibility is determined webpage. Here are some of the eligibility requirements for calendar year 2019.

Are you a physical therapist, occupational therapist, speech-language pathologist, registered dietitian, physician, osteopathic practitioner, chiropractor, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, clinical psychologist, or qualified audiologist who bills Medicare Part B for services? If no, you cannot participate in MIPS at this time.

Are you or your group participating in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) or a Qualifying Alternative Payment Model Participant (QP)? If yes, you are not eligible for MIPS.

Now think about how you bill Medicare for your services. Are you a part of a group practice that bills under its own tax identification number or do you bill individually? This will determine whether you should review qualifications as an individual or part of a group.

Do you or does your group exceed the low-volume threshold? To calculate this, you will need to review your Medicare Part B billing for the period of 10/1/2017 through 9/30/2018 which was released in December, 2018 and the period of 10/1/2018 through 9/30/2019 which is scheduled for release in November, 2019. You can register for access to your data on the QPP website. For both periods, (1) Medicare billing must exceed $90,000 for Part B services AND (2) billing must be for more than 200 Part B beneficiaries AND (3) 200 or more covered services must have been provided. If these criteria are met as an individual, then you are required to participate in MIPS as an individual. If these criteria are met as part of a practice, your group is required to report MIPS data. If you or your group only meet one or two of the low-volume threshold criteria, you are considered opt-in eligible.

For more details about eligibility, including Advanced Alternative Payment Models (APMs) and Virtual Groups, please review the how MIPS eligibility is determined webpage.

What is opt-in eligible?

Opt-in eligible means you have a choice of three options: (1) opt-in to report, (2) voluntarily report or (3) do not report at all. If you choose to opt-in to MIPS reporting, you will be required to track and report MIPS data, receive performance feedback on that data, receive any applicable payment adjustment (+ or – 7%) and have performance data published on Physician Compare. You cannot change your mind if your performance score is low and will result in a negative payment adjustment so carefully consider this option.

If you pick the voluntarily report option, you will receive performance feedback and have data published on Physician Compare but will not receive any payment adjustment based on performance. If your performance data is good, you will not receive a positive payment adjustment.

If you decide not to report at all, you will miss out on the opportunity to receive performance feedback and adjust practice procedures for future years, you will not have data published on Physician Compare and you will not receive a MIPS payment adjustment.

If your group is eligible or decides to opt-in, you will receive the group score and payment adjustment regardless of whether you individually decide to opt-in. Remember, you will only be treated as a member of the group if you have provided Medicare Part B billable services as part of that group. In this case, if you meet the criteria as an individual and believe you can achieve higher performance scores individually, you will want to opt-in as an individual. CMS will take the higher score between multiple submissions to determine individual payment adjustments.

See the Reporting Options Overview page of the QPP for more information.

MIPS timeframes

A performance period runs for the full calendar year. For example, the 2019 performance period will begin on January 1, 2019 and end on December 31, 2019. Quality performance category data must be collected for the full year. Improvement Activities and Promoting Interoperability data needs to be collected for at least a 90-day continuous period. Cost data will be analyzed for the year but will be calculated automatically by CMS based off of submitted claims that meet cost measure criteria. Data can be submitted from January 2nd through March 31st following the MIPS performance year. The deadline for data submission is March 31, 2020 for the 2019 performance period. You will receive feedback around July about the submitted data (so July, 2020 for 2019). MIPS payment adjustments are prospectively applied to each claim beginning January 1st of the year following the submission date (so January 1, 2021 for 2019).

If you are a qualified opt-in clinician or group, you will have to make your opt-in election during the submission period (before the end of the year). At this time, CMS is still finalizing operations and has not set a deadline. If you are considering being an opt-in clinician, keep an eye on the QPP website for any new information. If you are a member of a therapy organization like APTA, AOTA, ASHA, etc., make sure you are getting updates and are subscribed to their social media platforms for announcements.

So what do I do now?

Examine how your services are billed. Do you work for a company where you are given a paycheck for your services? You would be a group who bills under a single tax identification number with multiple NPI numbers and your participation will be considered at the group level. Check in with your company to find out what the group’s status is for MIPS reporting and, if participating, what information they will need from you. It will be up to the company to choose which measures they will be monitoring and reporting on as well as the method of getting the data together and reporting it.

If Medicare pays you directly for Part B services and you have a single tax identification number tied to a single NPI number, you are considered an individual. You should review the participation requirements to determine whether you are required, or wish to, participate. For 2019, analyze (1) your Medicare Part B billing, (2) the number of Medicare Part B patients you serviced, and (3) the number of services you billed for from January 1, 2019 through March 31, 2019. Multiply these numbers by 4 and you can approximate your annual statistics to see where you will fall. If your numbers for any criteria are under the threshold but close, you should put processes in place to collect data now so that you are not scrambling to catch up later.

If you decide to participate, you will need to choose how you will submit your data. As an individual or small practice (15 or fewer MIPS-eligible clinicians) group, you can choose to submit your data via claims for quality measures and manual entry on the CMS website for improvement activities. Any size group or individual can use a Qualified Clinical Data Registry (QCDR) to help gather and report on data. Look for the 2019 Qualified Clinical Data Registries (QCDRs) Qualified Postingin the QPP Resource Library for a spreadsheet of companies. Check the Specialty column of each page for your specialty or “All Specialties” to choose an appropriate vendor. One of the benefits of working with a QCDR is that they can alert you to low performance scores in advance so you can work to improve your documentation and care provision before the end of the year. If you choose to work with a QCDR, you should contact them as soon as possible to coordinate data reporting and get helpful advice to focus your MIPS program. We recommend working with a QCDR to help navigate this complicated system.

What data do I need to track?

The QPP website has lists of measures for 2019 for Quality Measures, Promoting Interoperability, Improvement Activities, and Cost Measures. You can review 2019 general requirements on the website for Quality Measures, Promoting Interoperability, Improvement Activities and Cost Measures as well.

Quality Measures

Quality Measures are generally worth 45% of your final score but could be worth up to 85%. Select your Specialty Measure Set to get a list of items you can choose to report on that are appropriate for your clinical practice. The “Specifications” link under any measure will tell you about that item, what CPT and/or diagnosis codes will trigger that data should be collected on the item, and what CPT codes you should report on your documentation and the claim to demonstrate your compliance with the measure. “Medicare Part B claims measures” will give you claims-based reporting instructions. You are required to submit at least 6 measures or, if your specialty has less than 6 applicable measures, all measures in your specialty set. Remember, if you are a part of a group, that group will select the quality measures to be reported and tracked.

An example of Quality Measure reporting may be helpful. If you choose to track the “Functional Outcome Assessment” measure (Quality ID 182), then for each patient over 18 years old, for each visit where a CPT code of 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, or 99215 was performed, a clinician would also document one of the following MIPS CPT codes:

Performance Met

  • G8539 – Functional Outcome Assessment Documented as Positive AND Care Plan Documented {functional deficiencies identified and included in care plan}
  • G8542 – Functional Outcome Assessment Documented, No Functional Deficiencies Identified, Care Plan not Required
  • G8942 – Functional Outcome Assessment Documented AND Care Plan Documented, if Indicated within the previous 30 days {functional outcome assessment tool is only required at least every 30 days – this code is used for visits in between}

Denominator Exception

  • G8540 – Functional Outcome Assessment not Documented, Patient not Eligible
  • G9227 – Functional Outcome Assessment Documented, Care Plan not Documented, Patient not Eligible

Performance Not Met

  • G8541 – Functional Outcome Assessment not Documented, Reason not Given
  • G8543 – Functional Outcome Assessment Documented as Positive, Care Plan not Documented, Reason not Given

If you choose to report via claims, you must report on at least 60% of all eligible visits to meet data completeness standards. You can verify that your code has been received by reviewing your remittance advice for code N620 and ensuring both the activity and MIPS CPT code are listed for the claim along with a valid place of service. For more information about claims-based reporting, review the 2019 Claims Data Submission Fact Sheet found in the QPP Resource Library.

Quality Measures can earn points based on three criteria and how they are met with some exceptions. Data completeness is generally met if the measure has been reported at least 60% of the time that it applies. Benchmark information for each measure can be found in the “Benchmark” link found under each measure. Sufficient volume is generally considered to be at least 20 cases but may vary based on the measure. So if data completeness and sufficient volume criteria are met and the measure has a benchmark, MIPS scoring will be between 3 and 10 points based on performance compared to the benchmark. If data completeness is met but either sufficient volume is not met or the measure does not have a benchmark, MIPS scoring will be 3 points. If data completeness is not met, MIPS scoring will be 1 point unless the submitter is a small practice which would give 3 points for the measure. Review the 2019 Quality Performance Category Fact Sheet found in the QPP Resource Library for more information.

Promoting Interoperability

Promoting Interoperability could be worth 25% of the MIPS final score for clinicians not under an APM. For 2019, Physical Therapists, Occupational Therapists, Speech Language Pathologists, Registered Dietitians and other clinicians qualify for automatic 0% reweighting and are not required to participate in this measure. Clinicians can receive an individual or group score just like Quality Measures but the reporting period is for a continuous 90 days and not the full year. See the 2019 MIPS Promoting Interoperability Fact Sheet found in the QPP Resource Library for more information.

Improvement Activities

Improvement Activities are worth 15% of the MIPS final score. A maximum of 40 points can be earned with 20 points for each high-weighted activity and 10 points for each medium-weighted activity. If you qualify for a special status (such as small or rural practice), you will receive double points for each activity you submit. The required performance period is at least a continuous 90 days during the calendar year. You can log in and attest to improvement activities measure data on the QPP website or submit through a QCDR.

We recommend keeping documentation of meeting the Improvement Activity measure on file to demonstrate compliance. For example, if you choose to attest to “Improved Practices that Disseminate Appropriate Self-Management Materials” (IA_BE_21), you should ensure that you have self-management materials developed and document that you provide these materials to eligible patients in their clinical record. See the 2019 Improvement Activities Performance Category Fact Sheetfound in the QPP Resource Library for more information.


Cost is worth up to 15% of the MIPS final score and is calculated based off of Medicare claims data. No additional submission is required of individuals or groups. Individual Physical Therapists, Occupational Therapists and Speech-Language Pathologists will be exempt from this measure for 2019. Included in this group of measures is the Total Per Capita Costs for All Attributed Beneficiaries (TPCC) and the Medicare Spending Per Beneficiary (MSPB). The TPCC evaluates overall efficiency of care provision and the MSPB evaluates spending efficiency. Eight episode-based measures focusing on selected diseases or procedures were developed for use in 2019.

CMS analyzes the cost in care provision, not including adjustments for geographic areas or other special circumstances, for all claims in the performance year and establishes a benchmark for each measure. CMS also establishes a case minimum for each measure. Each clinician/group who meets the case minimum will be evaluated on their risk adjusted performance in relation to the benchmark and receive a score. If the clinician/group receives a score in more than one area, all scores will be calculated to an equally-weighted average.

If no Cost measures can be scored, Quality Measures will be reweighted to 60%, Improvement Activities to 15% and Promoting Interoperability to 25% of the final score. For clinicians who do not meet Promoting Interoperability AND Cost requirements, Quality Measures will be reweighted to 85% and Improvement Activities to 15%. See the 2019 Cost Performance Category Fact Sheet found in the QPP Resource Library for more information.

The Wrap-Up

This is a complicated program with a lot of rules and exceptions. The best option for clinicians and group practices is to find a good Qualified Clinical Data Registry (QCDR) to help you if you are required to participate or choose to opt-in or voluntarily report. For 2019, if you have not started reporting via claims, it may be too late to start now to meet the data completeness 60% standard.

For official MIPS information, check out the CMS Quality Payment Program website. You can also review MIPS pages created by APTA, AOTA, and ASHA for additional, clinically focused assistance. Some content may only be available to members of these organization.

therapyBOSS can help. We now accommodate CPT code documentation so clinicians can report on selected measures. We are working on other features and reporting to make identification, data collection and reporting easier. To submit questions about this article, connect with us on Facebook.