Click on the link below and enter your individual NPI to determine if you are eligible to report MIPS.
If you're eligible to report MIPS in 2021, you will need to decide whether to report as an individual or as a group (i.e. on the TIN level). In 2021, the following clinicians will be included in MIPS:
- Physicians (including MD/DO, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)Physician Assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Physical therapists
- Occupational therapists
- Clinical psychologists
- Qualified speech-language pathologists
- Qualified audiologists
- Groups that includes such clinicians
- Clinicians who have billed more than $90,000 in Medicare Part B allowable charges, have more than 200 Part B-enrolled Medicare beneficiaries and provide more than 200 covered professional services to Part B patients
Clinicians who aren't included in MIPS
If you're exempt from MIPS in 2021, you do not need to report MIPS to avoid the automatic -9% penalty. For 2021, the following clinicians will be exempt from MIPS:
- Clinicians who enroll in Medicare for the first time in 2021
- Clinicians who participate in an Advanced APM and are either a Qualifying APM Participant (QP) or Partial QP
- Clinicians who meet the Low Volume Threshold (LVT):
- Clinicians who bill Medicare for $90,000 or less
- Clinicians who have provided care for 200 Medicare patients or fewer
- Clinicians who provide 200 or less covered professional services to Part B patients
- Clinicians who are not in a MIPS-eligible specialty (e.g. Licensed Social Work)
Clinicians participating in Advanced APMs
If you have a certain percentage of your Part B payments through an Advanced APM or see a certain percentage of your patients through an Advanced APM, you will not have to submit data to MIPS.
During the QPP performance period, CMS will take three "snapshots" (in July, October, and December) to see which clinicians are participating in an Advanced APM and whether they meet the thresholds to become Qualifying APM Participants (QPs).
If you participate in Advanced APMs, but don't meet the threshold, you may become a Partial QP. Partial QPs who do not meet the threshold can choose if they want to participate in MIPS.
In 2021, your eligibility will be reviewed at two different times in the year. If you are determined exempt during the first review, you won't have to submit any MIPS data for that reporting year as part of that practice(s).
CMS completed the first review for 2021 eligibility in December 2020 by examining claims from October 1, 2019 through September 30, 2020. CMS reviewed Medicare Part B Claims data and PECOS data and will only apply it to program year 2021.
CMS will do a second review in late 2021. CMS will review claims and PECOS data from October 1, 2020 through September 30, 2021. If you joined a new practice during this time period, your eligibility under that practice will be evaluated during the second review.
To check to see If you are clinician who needs to submit data to MIPS click on the link below and enter your National Provider Identifier (NPI) number into this tool.
How is Special Status calculated?
To determine if a clinician's participation should be considered as special status under the Quality Payment Program, CMS retrieves and analyzes Medicare Part B claims data. A series of calculations are run to indicate a circumstance of the clinician's practice for which special rules under the Quality Payment Program (QPP) will affect the number of total measures, activities or entire categories that an individual clinician or group must report. These circumstances are applicable for clinicians in: Small Practices, Non-patient facing, Health Professional Shortage Area (HPSA), Rural, Hospital Based, and Ambulatory Surgical Centers (ASC - POS24).
These tables explain the special status calculations.
Calculations for an individual clinician
|Small practice||The practice that the clinician is billing under has 15 or fewer clinicians.|
|Non-patient facing||The clinician has 100 or fewer Medicare Part B patient-facing encounters (including Medicare telehealth services) during the non-patient facing determination period.|
|HPSA||Practices in areas designated under section 332(a)(1)(A) of the Public Health Service Act.|
|Rural||Practices in zip codes designated as rural, by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP code file available .|
|Hospital based||The clinician furnishes 75% or more of their covered professional services in the inpatient hospital, on-campus outpatient hospital, off-campus outpatient hospital or emergency room settings (based on place of service codes POS19, POS21, POS22, POS23) during the applicable determination period.|
|Ambulatory Service Center (ASC) - based||The MIPS eligible clinician furnishes 75% or more of their covered professional services in sites of service identified by Place of Service (POS) code 24.|
Calculations for a Practice (TIN Level)
|Small practice||The practice has 15 or fewer clinicians billing under the practice.|
|Non-patient facing||The practice has more than 75% of the NPIs under the practice’s TIN meeting the definition of an individual non-patient facing clinician during the non-patient facing determination period.|
|HPSA||More than 75% of the clinicians billing under the group's TIN are designated as HPSA.|
|Rural||More than 75% of the clinicians billing under the group's TIN are in a Zip Code designated as rural using the most recent FORHP Zip Code file.|
|Hospital based||More than 75% of the clinicians billing under the group's TIN met the definition of hospital based services based on place of service codes (POS19, POS21, 22 and 23).|
|Ambulatory Service Center (ASC) - based||All MIPS eligible clinicians associated with the practice are designated as ASC-based (POS24).|
Special Statuses are assigned if you reach the requirement of at least one of the MIPS determination segments.
Certified Electronic Health Record Technology (CEHRT) Hardship Exception
Don’t have Certified Electronic Health Record Technology? You can apply for a Hardship Exception if you do not have Certified Electronic Health Record Technology (CEHRT). Certified electronic health record technology is required for participation in the Promoting Interoperability performance category of the Quality Payment Program (QPP). Under Merit-based Incentive Payment System (MIPS) scoring, MIPS-eligible clinicians and groups may qualify for a reweighting of their Promoting Interoperability performance category score to 0 percent (reweighed to the Quality category making it 70% of your final score) of the final score if they meet the criteria outlined. Simply lacking CEHRT does not qualify the MIPS-eligible clinician or group for reweighting.