Clinicians who need to submit data to MIPS
If you're included in MIPS in 2019, you will need to decide whether to report as an individual or as a group (i.e. on the TIN level). In 2019, these clinicians will be included in MIPS:
- Physicians (including doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
- Osteopathic practitioners
- 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 and have more than 200 Part B-enrolled Medicare beneficiaries
Clinicians who aren't included in MIPS
If you're exempt from MIPS in 2019, you won't need to report MIPS to avoid the automatic -5% penalty. For 2019, the following clinicians will be exempt from MIPS:
- Clinicians who enroll in Medicare for the first time in 2019
- Clinicians who participate in an Advanced APM and are either a Qualifying APM Participant (QP) or Partial QP
- Clinicians who bill Medicare for $90,000 or less
- Clinicians who have provided care for 200 Medicare patients or fewer
- Clinicians who are not in a MIPS-eligible specialty
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" (on March 31, June 30, and August 31) 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 can choose if they want to participate in MIPS.
In 2019, 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 in December 2018 by examining claims from October 1, 2017 through September 30, 2018. CMS reviewed Medicare Part B Claims data and PECOS data and will only apply it to program year 2019.
CMS will do a second review in late 2019. CMS will review claims and PECOS data from October 1, 2018 through September 30, 2019. If you joined a new practice during this time period, your eligibility under that practice will be evaluated during the second review.
Check if you are clinician who bills to Medicare and needs to submit data to MIPS by simply entering 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: Health Professional Shortage Area (HPSA), Rural, Non-patient facing, Hospital Based, and Small Practices.
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, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data.|
|Hospital based||The clinician furnishes 75% or more of their covered professional services in the inpatient hospital, on -campus outpatient hospital, or emergency room settings (based on place of service codes) during the applicable determination period.|
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||The practice has at least one clinician that is designated as Health Professional Shortage Area.|
|Rural||The practice has at least one clinician that is designated as rural.|
|Hospital based||All clinicians associated with the practice are hospital based, provided that 75% or more of the practice’s covered professional services are furnished in the inpatient hospital, on -campus outpatient hospital, or emergency room settings (based on place of service codes) during the applicable determination period.|
For non-patient facing MIPS eligible clinicians, these calculations are run twice using the same time frame of claims of service that is used to determine whether clinicians fall below the low volume thresholds.If the two calculations to determine any of these special, non-patient facing status circumstances differ from one from another, the clinician or practice will receive the special status.
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 advancing care information 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 advancing care information performance category score to 0 percent of the final score if they meet the criteria outlined. Simply lacking CEHRT does not qualify the MIPS-eligible clinician or group for reweighting.