MIPS Overview

The Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), is a quality payment incentive program for physicians and other eligible clinicians, which rewards value and outcomes in one of two ways:

  • The Merit-Based Incentive Payment System (MIPS) and
  • The Advanced Alternative Payment Models (APMs)

MIPS combined 3 existing quality and value reporting programs into one: the Physician Quality Reporting System (PQRS); the Value-Based Modifier (VBM); and the EHR Meaningful Use (MU) program.  MIPS also adds a 4th component for practice improvement activities (CPIA).  Most providers will initially participate in Medicare through MIPS.  

The 4 scoreable MIPS categories in 2018 are:

  • Quality 
  • Advancing Care Information 
  • Improvement Activities (new in 2017)
  • Cost 

When did MIPS begin?

The program began in 2017, with payment adjustments beginning in 2019.  

Who is eligible to participate in MIPS?

MIPS eligible clinicians include:

  • Physicians
  • Physicians assistants
  • Nurse practitioners
  • Clinical nurse specialists; and
  • Nurse anesthetists
  • ***This list may be expanded by CMS in 2019 to include other types of providers (e.g., physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals)

MIPS non-eligible clinicians would be permitted to voluntarily report under MIPS in 2018, but will not be subject to the MIPS payment adjustment.

To check if you need to submit 2018 MIPS data, please visit the CMS Quality Payment Program website.

Are any providers exempt from MIPS?

Yes, the following providers would be exempt from MIPS:

  • Newly enrolled in Medicare (exempt until the following performance year)
  • Clinicians meeting a low-volume threshold ($90,000 or less in billed Medicare Part B allowed charges AND provide care for 200 or fewer Medicare Part-B enrolled patients in one year)
  • Clinicians significantly participating in "alternative payment models" (APMs)

To check if you need to submit 2018 MIPS data, please visit the CMS Quality Payment Program website.

Can providers participate in MIPS as an individual provider or a group practice?

Providers can participate in MIPS as either:

  • An individual (defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN); or
  • A group defined as a set of clinicians (identified by their individual NPIs) sharing a common TIN.

A group would be measured as a group practice across all 4 MIPS performance categories. Solo providers and small practices may be able to join “virtual groups” in future years to combine their MIPS reporting.

How does MIPS work?

Providers participating in the MIPS program will receive a “composite performance score” based on their performance in 4 categories:  

(replaced PQRS)

50% of total score 

(Decreases to 30% in 2019 and thereafter)

Advancing Care Information
Advancing Care Information (ACI)
(replaced EHR Meaningful Use)

25% of total score 
Improvement Activities
Improvement Activities (new in 2017)
15% of total score 

(based on admin. claims data)

10% of total score 

(Increases to 30% in 2019 and thereafter)

How is the Quality category different in 2018?

  • Each provider must report 6 individual measures or a specialty measure set (one must be an outcome measure, or if no outcome measure is available, a high priority measure).
  • Providers reporting on quality measures must report on at least 60% of their eligible Medicare and non-Medicare patients who are eligible for the measure.
    • Providers whose measures fall below the data completeness threshold of 60% would receive 1 point for submitting the measure.  Small practices will still earn 3 points for a measure that falls below data completeness.
  • There are no domain requirements.
  • CAHPS is no longer required for groups of 100 or more.
  • *View the list of the Quality measures: https://qpp.cms.gov/measures/quality
  • The 7-point scoring policy for 6 topped out measures identified for the 2018 performance period is finalized. These 6 topped out measures include the following:

    • Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin. (Quality Measure ID: 21)

    • Melanoma: Overutilization of Imaging Studies in Melanoma.(Quality Measure ID: 224)

    •  Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients). (Quality Measure ID: 23)

    • Image Confirmation of Successful Excision of Image- Localized Breast Lesion. (Quality Measure ID: 262)

    • Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description (Quality Measure ID: 359)

    • Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Quality Measure ID: 52)

  • Quality improvement scoring (new in 2018):  Up to 10% point available for improvement in the Quality category.

Will there be a Measure Applicability Validation (MAV) process under MIPS if I cannot report 6 measures?

CMS developed a process called EMA to review and validate a provider’s inability to report on the quality performance requirements under MIPS.  This validation process will be part of the quality performance category scoring calculations and not a separate process as the MAV was under PQRS.  This process will apply for claims and registry submissions to validate whether MIPS eligible clinicians have submitted all applicable measures when MIPS eligible clinicians submit fewer than six measures or do not submit the required outcome measure or other high priority measure if an outcome measure is not available, or submit less than the full set of measures in the MIPS eligible clinicians’ applicable specialty set.

How will the Improvement Activities category work?

  • Performance in this category is calculated based on the provider’s attestation to completing 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days.  Some examples of improvement activities include care coordination, beneficiary engagement and patient safety activities.  
  • For small practices (less than 15 in the TIN), rural practices, or practices located in geographic health professional shortage areas (HPSAs), providers are only required to report 1 high-weighted or 2 medium-weighted activities for full participation.
  • In 2018, there are approximately 112 published activities (up from 92 in 2017).

*View the list of Improvement Activity measures:  https://qpp.cms.gov/measures/ia

*Click here to download the Improvement Activity Data Validation criteria from the CMS QPP website.

How will the Advancing Care Information category work?

  • Performance in this category is calculated based on the submission of 5 EHR (or 4 depending on the EHR edition) use-related measures for a minimum of 90 days in 2018.  These base measures are required in order to then go on to earn additional performance and bonus points.
  • Base Measures include: security risk analysis; e-prescribing; providing patient access; sending summaries of care; and requesting/accepting summaries of care.

*View the list of the Advancing Care Information measures: https://qpp.cms.gov/measures/aci

How will my Medicare payments be impacted under MIPS?

MIPS eligible clinicians will receive neutral, positive or negative payment adjustments based on their composite performance score.   The maximum negative adjustments are: 5% in 2020, 7% in 2021, and 9% in 2022 and subsequent years.  Exceptional performers could receive positive adjustments up to 3x this amount.  The threshold for these payment adjustments will be the mean or median composite score for all MIPS eligible clinicians during the previous performance period.

Where can I get more information?

You can find additional information on the CMS website at: https://qpp.cms.gov/

What do I need to do now to prepare for MIPS?

Determine your eligibility

Pick your measures

Decide if you will be reporting as a group or as individuals

What mechanism will you use to report each component of MIPS?

Will MDinteractive still submit my data to CMS?  

Yes!  We will offer 3 services to help you report:

  • Data on Quality 
  • Improvement Activities 
  • Advancing Care Information  (requires use of a certified EHR)


Further information can be found at:

Register with MDinteractive