Frequently Asked Questions


A practice does not have to register directly with CMS to report as a group.  This option is open to all practices with 2 or more providers billing within the same TIN.  If you have previously reported as individuals and will be reporting as a group in the current reporting year, we ask that you contact us at to let us know so that we can modify your account.

Note that if you are reporting one component of MIPS as a group, you will be evaluated as a group for all of the components.

MDinteractive provides CMS with the reporting and performance rate calculations for the measures submitted by a provider (using the combination of the individual NPI/TIN as the identifier).  Individual patient information is not submitted to CMS.

To prevent actions that block the exchange of health information, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program final rule with comment period require MIPS eligible clinicians to show that they have not knowingly and willfully limited or restricted the compatibility or interoperability of their certified electronic health record (EHR) technology. MIPS eligible clinicians show that they are meeting this requirement by attesting to three statements about how they implement and use certified EHR technology (CEHRT). Together, these three statements are referred to as the “Prevention of Information Blocking Attestation.”

Do I Have to Attest?

If you are a MIPS eligible clinician who reports on the advancing care information performance category you must attest to the prevention of information blocking attestation. If you are reporting as a group, the prevention of information blocking attestation by the group applies to all MIPS eligible clinicians within the group. Therefore, if one MIPS eligible clinician in the group fails to meet the requirements of the Prevention of Information Blocking Attestation, then the whole group would fail to meet the requirement.

What Actions Are Required?

If you want to earn a score for the advancing care information performance category, you have to act in good faith when you implement and use your CEHRT to exchange electronic health information. This includes working with technology developers and others who build CEHRT to make sure the technology is used correctly and is connected (and enabled) to meet applicable standards and laws. You must also ensure that your organizational policies and workflows are enabled and do not restrict the CEHRT’s functionality in any way. For example, if your CEHRT gives patients access to their electronic health information or exchanges information with other MIPS eligible clinicians, your practice must use these capabilities.

Statements to Which I Am Attesting

  1. A MIPS eligible clinician must attest that they did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of CEHRT. Statement 1 requires MIPS eligible clinicians to demonstrate that they did not knowingly and willfully take action to limit or restrict the compatibility or interoperability of CEHRT.
  2. A MIPS eligible clinician must attest that they implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the CEHRT was, at all relevant times
    1. Connected in accordance with applicable law;
    2. Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR Part 170;
    3. Implemented in a manner that allowed for timely access by patients to their electronic health information (including the ability to view, download, and transmit this information);
    4. Implemented in a manner that allowed for the timely, secure, and trusted bidirectional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated providers, and with disparate CEHRT and health IT vendors.
  3. A MIPS eligible clinician must attest that they responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor’s affiliation or technology vendor.

Do I Have to Show Any Documentation to Attest?

You do not have to give us any documentation to show you have acted in good faith to:

  • Implement and use your CEHRT to support the appropriate exchange of electronic health information.
  • Not block information

Where Can I Learn More?

The Merit-based Incentive Payment System (MIPS) Advancing Care Information Prevention of Information Blocking Attestation: Making Sure EHR Information is Shared

Click here to find suggested documentation to keep regarding specific Improvement Activities. You might be asked to provide supporting documentation for any activities you attest to prior to submission.

Other general suggestions:

  1. List the start date and end date for each activity
  2. Describe the goals, outcomes or metrics for each activity
  3. Describe the process being improved and the benefit of improving the process
  4. List the staff involved for each activity
  5. List the technology used. If possible take screenshots
  6. Describe workflows
  7. Document improvement activities compliance
  8. Describe monitoring systems to gauge your progress towards the goals
  9. Store all documentation in computer files

Eligibile clinicians submitting via claims or a qualified registry who submit less than 6 measures or no outcome or high priority measure will be subject to EMA (Eligibility Measure Applicability) process to determine if additional clinically related measures could have been submitted. If CMS determines that there are no applicable measures for the clinician, they won't be held accountable for not submitting those measures.  If CMS discovers that additional clinically related measures could have been submitted and were not, it will impact the Quality performance category final score.  

EMA is...

An enhanced version of MAV (Measure Applicability Validation)

Adjusts performance in the quality performance category when appropriate

Based on evaluation of submitted measures and determination of clinically related measures aligned with specialty measures sets

Specific to the submission mechanism. For example, EMA will not determine that a registry submitter had a claims measure available.

Not applicable to EHR, QCDR and Web interface data submission mechanisms

Process Measures - Process measures show what doctors and other clinicians do to maintain or improve health, either for healthy people or those diagnosed with a given condition or disease.  These measures usually reflect generally accepted recommendations for clinical practice.  Process measures can tell consumers about medical care they should receive for a given condition or disease, and can help improve health outcomes.

Outcome Measures - Outcome measures show how a health care service or intervention influences the health status of patients. Examples:  The % of patients who died becauses of surgery or the rate of surgical complications or hospital acquired infections.  Outcome measures are the result of many factors, some of which may be out of a clinician's control. An Outcome Measure is also classified as High Priority.  CMS asks for an Outcome Measure to be reported as part of the 6 total measures (if one is applicable).

High priority Measures - High priority measures include the following categories of measures:  Outcome, Appropriate Use, Patient Experience, Patient Safety, Efficiency measures, Care coordination.



Quality Performance Category: Your ACO is required by the Shared Savings Program to report quality measures through the CMS Web Interface. The quality data reported to the CMS Web Interface by the ACO will be used to score the MIPS Quality performance category and the score will apply to each MIPS clinician in the ACO.

Improvement Activities and Cost Categories: As a MIPS clinician in the Shared Savings Program ACO you won’t need to report any data for the MIPS Improvement Activities performance category because you will automatically receive full points for this category. In addition, MIPS clinicians in a Shared Savings Program ACO will not be assessed on the MIPS Cost performance category.

Promoting Interoperability (formerly ACI) Category: All ACO participant TINs in a Shared Savings Program ACO, including ACO participant TINs that are in a Track 2 or 3 ACO, are responsible for submitting data for the Promoting Interoperability performance category apart from the ACO as specified by MIPS. This information is necessary for the Shared Savings Program to measure the level of CEHRT use among clinicians participating in the ACO.

APM Scoring Standard: The Shared Savings Program is a MIPS APM, and all MIPS clinicians in Shared Savings Program ACOs will receive special scoring for MIPS under the APM scoring standard. Consequently, all MIPS clinicians in your ACO will receive the same MIPS final score.

What if my ACO does not successfully report quality measures through the CMS Web Interface? While unlikely, since most ACOs successfully report quality measures through the CMS Web Interface, if you believe your ACO won’t report what it needs to under the Shared Savings Program, your ACO 4 Quality Payment Program Fact Sheet participant TIN can submit quality data for the performance year under any of the MIPS standard reporting options. If the ACO doesn’t meet its reporting requirements, we’ll look for and use any quality data for the performance year that your ACO participant TIN sent in apart from the ACO to score your quality domain under MIPS. Your ACO participant TIN will still receive full points for the MIPS Improvement Activity performance category and it will not be assessed on the MIPS Cost performance category. Your ACO participant TIN will still need to report for the Advancing Care Information category according to the MIPS requirements for this category. Instead of being scored at the ACO level, the MIPS clinicians under each ACO participant TIN will receive their own MIPS final score.

For More Information:

Certified electronic health record technology (CEHRT) 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 of the final score if they meet the criteria outlined below. The 25 percent weighting of the Promoting Interoperability performance category would be reallocated to the Quality performance category. Simply lacking CEHRT does not qualify the MIPS-eligible clinician or group for reweighting. MIPS-eligible clinicians and groups that are participating in a MIPS Alternative Payment Model may be exempted from reporting information for the advancing care information performance category if they meet the criteria outlined below:

A MIPS-eligible clinician or group may submit a Quality Payment Program Hardship Exception Application, citing one of the following specified reasons for review and approval:

  • MIPS-eligible clinicians in small practices 
  • MIPS-eligible clinicians using decertified EHR technology 
  • Insufficient Internet connectivity
  • Extreme and uncontrollable circumstances
  • Lack of control over the availability of CEHRT

Special Status Clinicians

There are some MIPS-eligible clinicians that are considered Special Status, who will be automatically reweighted (or exempted in the case of MIPS-eligible clinicians participating in a MIPS APM) and do not need to submit a Quality Payment Program Hardship Exception Application.

Special Status clinicians include the following:

  • Hospital-based MIPS-eligible clinicians
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Non-patient facing clinicians
  • Ambulatory Surgical Center (ASC) Based MIPS-Eligible Clinicians
  • NEW:  Small practices will automatically receive a re-weight of the PI category beginning in 2022

A group’s Promoting Interoperability performance category score is automatically reweighted, (or exempted in the case of groups participating in a MIPS Alternative Payment Model (APM)), and the group would not need to submit a Quality Payment Program Promoting Interoperability Hardship Exception Application if all of their MIPS-eligible clinicians within the group receive a hardship exception or fall into one or more of the Special Status categories above, with the exception of a non-patient facing group which only requires that 75 percent of clinicians are non-patient facing.

In addition, a group is automatically reweighted (or exempted) and does not need to submit a Quality Payment Program Hardship Exception Application if it is non-patient facing. Groups are considered non-patient facing if more than 75 percent of its clinicians have 100 or fewer patient-facing encounters (including Medicare telehealth services).

If all of the MIPS-eligible clinicians within a group do not qualify for an automatic reweighting or do not submit an application for and receive a hardship exception, the group will not qualify for an automatic reweighting and will have to report on the Promoting Interoperability performance category.

Improvement Activities are sorted into subcategories which might help you locate activities that are applicable to your practice. Note that when using the MIPS Measures Planning and MIPS Measures Reporting tools within the MDinteractive software, you can filter the list of IA's by sub-category:

1. Achieving Health Equity: Engagement of new Medicaid patients and follow-up.

2.  Behavioral and Mental Health:  Activities that look at the co-morbidity of mental health and physical health.  Some cross-over with Quality measures.

3.  Beneficiary Engagement:  Engagement of patients through post-visit surveys, tracking reported outcomes, using care plans to manage chronic conditions.

4.  Care Coordination:  Coordination of care between clinicians. Health information exchange, coordinated planning, etc.

5.  Emergency Response & Preparedness:  Supporting communities by registering to be part of a disaster relief team or participation in supporting humanitarian needs.

6.  Expanded Practice Access:  How accessible you are to your beneficiaries?

7.  Patient Safety and Practice Assessment Population Management:  Patient safety monitoring programs (i.e. prescriptions drug monitoring, appropriate use of antibiotics, etc.

8.  Population Management:  Population health. Using research, tools, etc.

Note: Many of the medical society sites have posted suggestions for their specialties for the IA category.  MDinteractive also provides suggestions in our Suggestions by Specialty section of the website.


Clinicians practicing in RHCs or FQHCs who provide services that are billed exclusively under the RHC or FQHC payment methodologies are not required to participate in MIPS (they may voluntarily report on measures and activities under MIPS) and are not subject to a payment adjustment.

However, if these clinicians provide other services and bill for those services under the Physician Fee Schedule (PFS), they would be required to participate in MIPS and such other services would be subject to a payment adjustment.

Clinicians included in MIPS and practicing in CAHs are required to participate in MIPS unless they are exempt.

For MIPS clinicians practicing in Method I CAHs, the MIPS payment adjustment would apply to payments made for items and services that are Medicare Part B allowed charges billed by the MIPS clinicians. The payment adjustment would not apply to the facility payment to the CAH itself.

For MIPS clinicians practicing in Method II CAHs who have assigned their billing rights to the CAH, CMS would apply the MIPS payment adjustment to the Method II CAH payments. For MIPS clinicians practicing in Method II CAHs that have not assigned their billing rights to the CAH, the MIPS payment adjustment would apply in the same way as for MIPS clinicians who bill for items and services in Method I CAHs.

All MIPS clinicians will report data for the Promoting Interoperability performance category as usual according to the general MIPS requirements. MIPS clinicians can report their Promoting Interoperability data via attestation and the CMS Web Interface (only available for groups of 25 or more), which you can access via, as well as through a QCDR, Qualified Registry like MDinteractive, or Certified EHR technology (CEHRT).

All Medicare Shared Savings Program ACO participant Tax Identification Number’s (TINs) must report the MIPS Promoting Interoperabiliyy performance category regardless of whether they meet the QP thresholds or not. The Medicare Shared Savings Program ACO participant TIN scores for this performance category will becombined as a weighted average based on how many MIPS clinicians are in each TIN. This will result in one ACO group score for the Advancing Care Information performance category that applies to all MIPS clinicians in the ACO.

For the Next Generation ACO model and all other MIPS APMs under the APM scoring standard, MIPS clinicians in the APM report on the Promoting Interoperability performance category through either a group TIN or individual reporting. We’ll score each MIPS clinician in the APM using the highest score for the TIN/NPI combination for each MIPS clinician, which may be from individual or group reporting. The score given to each MIPS clinician will be averaged with the scores of the other clinicians in the APM Entity group to produce one APM entity score for the Promoting Interoperability performance category.

The Promoting Interoperability performance category for the 2022 performance period is weighted at 30 percent for the Medicare Shared Savings Program and the Next Generation ACO model MIPS APMs. For all other MIPS APMs this performance category is weighted at 75 percent for the 2022 performance period.

For further info please see:

MIPS APM Fact Sheet: Provides an overview of a specific type of APM, called a "MIPS APM," and the special APM scoring standard used for those in MIPS APMs.

For Registry, EHR, and QCDR providers must have a minimum of one eligible Medicare Part B Patient (regardless of how many Measures you Report) in order to utilize that Reporting Option. There should be one Medicare patient in the denominator of at least one measure (out of the required six). The Medicare patient does not have to be in the numerator (e.g. met the measure).

Example: If one reports 6 measures via EHR, Registry, or QCDR -- one only needs "1" eligible Medicare patient total in order to meet the minimum requirements.

Note:  Providers should only choose and report on measures where they have at least one eligible Medicare case that qualifies for the measure. That patient/case does not have to be included in the report for that measure however (as long as you have at least 1 Medicare patient in 1 of your Quality measure reports).


Data completeness criteria is to report on at least 70% of all eligible cases (meet the denominator criteria) for a measure regardless of payer.

CMS defines a patient-facing encounter as an instance in which a MIPS eligible clinician billed for services such as general office visits, outpatient visits, and procedure codes under the Medicare Physician Fee Schedule.

What is the Patient-facing Encounters Codes List?
This list of patient-facing encounter codes is used to determine the non-patient facing status of MIPS eligible clinicians. A non-patient facing MIPS eligible clinician is:

  • An individual MIPS eligible clinician that bills 100 or fewer patient-facing encounters (including Medicare telehealth services defined in section 1834(m) of the Act) during the non-patient facing determination period, and
  • A group provided that more than 75 percent of the clinicians billing under the group’s TIN meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period.

The list of patient-facing encounter codes are categorized into three overarching groups of codes:

  • Evaluation and Management Codes 
  • Surgical and Procedural Codes, 
  • Visit Codes 

The utilization of Evaluation and Management Codes, Surgical and Procedural Codes, and Visit Codes accurately classifies MIPS eligible clinicians as non-patient facing and patient-facing.

Given the flexibility in program requirements for non-patient facing clinicians, the encounter codes are critical for CMS to identify MIPS eligible clinicians.

The reporting rate is the percentage of times that you answered all of the questions related to a particular measure.  For individual measures, your reporting rate must be at least 70% meaning you reported the quality measure on at least 70% of those who were eligible, regardless of insurance type.  If you create more than 70% of your eligible cases for a measure, you must provide the answers/numerator option for at least 70% of the records entered.  If you do not meet this threshold, the software will alert you.

The performance rate is the percentage of times you met the measure (answered "done" or "performed") compared to the number of eligible patients entered for the measure.   Numerator (# of times measure is met)/Denominator (number of eligible case for the measure).  Note that answering with an exclusion option (if applicable) will take the eligible case out of the Denominator prior to final calculation of the performance rate.  This will still count towards your reporting rate however.

Performance rates of 100% are a perfect score. There are measures (i.e. Measure 1 Hemoglobin A1c) where a lower calculated performance rate is better.  These are called inverse measures and a performance rate of 0% would be a perfect score.

Your individual NPI is used to report MIPS.

The 24J field on your claims should contain the individual NPI. The TIN in field 25 and the individual NPI listed in 24J should always be used to report MIPS.

If you look at your claim forms you will see that there are two different spots for NPIs. The 33a field is where the Group NPI is listed. Please do not report MIPS using the Group NPI.


For the Quality component of MIPS, each individual measure is reported on at least 70% of the clinician or group's eligible Medicare and non-Medicare patients.

When reporting a MIPS Quality measure, a provider must report on at least 70% of all Medicare and non-Medicare patients who meet the eligibility criteria for that measure.  In order to achieve more than just the base points for a measure (3 points for practices with 15 or fewer providers or 1 point for practices with 15+), only measure reports containing at least 20 patients/records in the denominator will be scored (compared against national benchmarks) for possible additional points.  

Yes.  Each Quality measure is reported on at least 70% of all eligible cases - Medicare and non-Medicare - for the calendar year.  Measures that are reported with less than 20 cases will earn 0 points (3 points for small practices with 15 or less providers under the TIN) and will not be scored against national benchmarks.

Yes, a provider can submit data via another submission method and CMS will make their payment adjustment based on the most complete set of data received,

MIPS reporting of individual measures applies to all patients. Eligibility for a measure is based on CMS documentation (denominator criteria).

A practice can report as individuals or as a group via MDinteractive.

Group reporting is available to practices of 2 or more providers operating under a single TIN. If at least one provider in the group has eligible patient visits to report, every member of the group will avoid the MIPS penalty.

When reporting as a group, each Quality measure is reported on at least 70% of eligible cases across the TIN.  MIPS ineligible clinicians (due to falling below the low volume threshold for example) are included when calculating how many cases to report for a measure.  The QPP participation site will provide guidance on which providers are included when reporting as a group.


The CAHPS for MIPS survey is optional for all groups of 2 or more eligible clinicians, but MIPS provides several incentives for groups to participate.

  • The CAHPS for MIPS survey counts as one measure toward the MIPS quality performance category, as a patient experience measure, and fulfills the requirement to report at least one high priority measure in the absence of an applicable outcome measure. Groups must report at least 5 additional quality measures using another data submission method. The CAHPS for MIPS survey is also included in the improvement activities performance category as a high-weighted activity.
  • Groups, virtual groups, and APM Entities, including Shared Savings Program ACOs that don’t meet the minimum sample sizes can’t administer the CAHPS for MIPS Survey.
  • In order for groups to elect participation in the 2018 CAHPS for MIPS survey, they must register by June 30, 2022. Registration must be completed online through the MIPS Registration System. During registration, groups must indicate if they are selecting the CMS Web Interface reporting mechanism as well as elect to administer the CAHPS for MIPS survey. For additional information on registration and requirements please refer to
  • More information can be found at CAHPS for MIPS Fact Sheet

Non-patient facing MIPS eligible clinicians will have their PI category automatically reweighted to zero by CMS.


MDinteractive FAQs

Yes!  You can also use MDinteractive to attest to the Promoting Interoperability (PI) and Improvement Activities (IA) categories of MIPS.

Promoting Interoperability requires that you have CEHRT technology.  You do not need to have an EHR to attest to Improvement Activities.

Advantages of registry reporting vs. claims include:

  • Reliabilty:  Registries are more reliable. Per CMS, "18 percent of those who attempted to participate via claims were unable to submit any measures satisfactorily, compared to 1 percent for those using a registry". 
  • Ability to Edit Data Before Submission: With claims based reporting once you file a claim with quality codes on it, you can't correct it or make changes on it.
  • Avoids Extra Work Coding Claims: Each quality measure may involve 1 or 2 G-codes. Depending on the quality measures chosen, you may need to send a claim with 9 extra lines to do the reporting.
  • Maximize Your Score: If you change you mind during the year and you would like to report another measure(s) where you can reach higher performance, you can't do it with claims reporting. CMS expects every measure reported to reach a 60% reporting rate or else the submission will fail. With the registry, you can choose to report only the measures that will maximize your quality scores.
  • Ability to Track Performance: Tracking performance with claims reporting is very difficult. Once some clinical data is entered into the registry, you can see your performance in a dashboard anytime you login.
  • Low Cost for Reporting: The registry fee is lower than the potential loss of revenue if claims reporting fails. For example, according to the last available PQRS experience report, only 114,513 providers reported PQRS successfully out of 283,837 providers using the claims reporting method. The claims success rate was 40%.
  • Better Opportunity for Upward Adjustments: Per CMS, "among individual participants, incentive eligibility rates were 93 percent among those using registry measures groups, 59 percent for registry individual measures, 57 percent for EHR, 43 percent for QCDR, and 40 percent among eligible professionals participating via claims."
  • Accuracy: Per CMS, "for the claims reporting mechanism, the main challenges to satisfactory reporting  included:
    1. failure to identify eligible patients or claims;
    2. Quality Data Code submission errors;
    3. failure to submit Quality Data Codes for at least 50 percent of eligible instances". 
  • Customer Support Service:  Working with a registry doesn't just mean working with the software.  We have a MIPS educated and dedicated staff that will help you avoid a potential penalty and achieve the highest earning potential based on your practice goals. 

There are many advantages to submitting your MIPS data via a qualified CMS registry.  These include:  

  • You may enter and begin validating your data throughout the year, or all at once eliminating the need to track claims;
  • Some individual measures are registry only;
  • MDinteractive reviews your data prior to submitting to CMS;
  • MDinteractive is easy to use and the system clearly identifies potential errors before submission to CMS;
  • CMS has demonstrated that providers using registries were significantly more likely to avoid penalties (and earn incentive in previous years) when compared to claims-based reporting.

MDinteractive supports all MIPS Quality registry-based and EHR measures.  (MIPS CQM and eCQM.)

A list of all available measures can be found here.

Note:  MDinteractive can also be used to attest to the PI and IA categories of MIPS (all available measures and activities).

Register with MDinteractive