Don't Get Left Behind: Checklist to Jumpstart Your 2023 MIPS Reporting

Posted on April 21, 2023

The Merit-based Incentive Payment System (MIPS) continues to evolve and is becoming increasingly difficult for eligible clinicians to optimize their MIPS scores. While the minimum score to meet the performance threshold in 2023 remains at 75 points, achieving this score can be a challenge without careful planning. This 2023 MIPS checklist provides tips on how to get ahead of the pack and ensure the best possible outcome at the finish line.

2023 MIPS Reporting Checklist

Step 1:  Review your 2023 MIPS eligibility status: Are you required to report MIPS in 2023?

The CMS QPP Participation Status Lookup Tool has been updated for the new performance year so you can now verify your initial eligibility status. Your final eligibility status will be updated sometime in December. If you are not required to report MIPS in 2023, you may be able to opt-in and report, or you can choose to voluntarily report your performance data.

Enter your 10-digit individual National Provider Identifier (NPI) here to check your status now. Make sure you’re viewing your performance year 2023 eligibility status. The tool will tell you:

  • If you are required to report MIPS for any practice(s) in 2023
  • If you are MIPS eligible as a group
  • If you are a Qualifying Alternative Payment Model (APM) participant (QP) or a Partial QP and not required to report MIPS*
  • If you are an opt-in eligible clinician
  • If you have any special status designation (e.g., Small Practice, Ambulatory Surgery Center (ASC)-based, Hospital-based, Facility-based, Non-patient Facing, Health Professional Shortage Area (HPSA) or Rural)  

*CMS will review APM participation 4 times for each performance year (called “snapshots). This information will be updated on the QPP website in July, October, December, and March (2024).

MIPS eligibility status should be checked again at the end of 2023 for any changes. Your eligibility status may change if you started billing Medicare Part B claims under a new practice/Tax Identification Number (TIN) between October 1, 2022 - September 30, 2023, or joined an APM Entity in later snapshots.

You are required to participate if ALL of the following are true:
You are a MIPS-eligible clinician type.You exceed all 3 elements of the low-volume threshold as an individual or are participating as a group that exceeds the low-volume threshold.*You enrolled in Medicare before January 1, 2023.You don’t become a
Qualifying APM
Participant (QP) or
Partial QP.

*A clinician who bills more than $90,000 for Medicare Part B covered services, sees more than 200 Part B patients, and provides more than 200 covered professional services to Part B patients.

Step 2:  Determine if you will report as an individual or a group:  Which option is right for you?

You have the option to participate in MIPS as a group if your practice (identified by the TIN):
  • Exceeds the established low-volume threshold OR is eligible to opt-in as a group; and
  • Has at least 2 clinicians billing under the group’s TIN; and
  • Includes at least 1 MIPS eligible clinician. 

Now that you have confirmed your eligibility, decide if you will report as an individual clinician or as a group. When reporting as a group, performance data is aggregated across the TIN for all clinicians, which could include covered professional services furnished by clinicians within the TIN who aren’t required to participate in MIPS. Clinicians in the group will receive the collective score of the group for all 4 MIPS categories and the same payment adjustment as everyone else in the group. There will be one MIPS submission under your TIN, rather than a separate submission for each clinician.  

Step 3:  Develop Your Reporting Plan:  Will you report traditional MIPS or a new MVP?

Starting in 2023, clinicians can report traditional MIPS or an MVP ( a new reporting option that involves a standardized set of measures across MIPS performance categories related to a particular episode or condition). All MIPS categories and options can be reported with MDinteractive (Quality, Improvement Activities, and/or Promoting Interoperability). The Cost category is calculated based on claims submissions and does not require any separate reporting.

You should become familiar with the MIPS program requirements for 2023, and develop a plan with specific goals and deadlines for each performance category. If you plan to report an MVP you must complete a new MVP registration process by November 30, 2023, and notify MDinteractive of your decision.

Choose your Quality measures.

  • Select 6 Quality measures (at least 1 measure should be an Outcome or High Priority measure); a specialty measure set, or an MVP and determine how your data will be collected.  NOTE: MVP participants select 4 quality measures from the list of Quality measures in the MVP (1 must be an outcome or a high-priority measure). If applicable, an administrative claims measure that is outcome-based may be selected to meet the outcome measure requirement.

  • CMS retires Quality measures each year, so confirm the measures you want to report are still available in 2023 and check the CMS documentation to see if there are any changes to how the measure gets reported.

  • Pay attention to Quality measure benchmarks to understand how many points you can earn based on your performance for each measure. Reporting “topped out” measures, where the maximum score is capped, will make it harder to optimize your Quality score. 

  • Remember, Quality measures must meet the CMS data completion rules. This means each measure must be reported on at least 70% of eligible encounters, regardless of insurance, for the entire year (January 1st through December 31st).

Select and attest to the required amount of Improvement Activities (IA) that are relevant to your practice and patient population.

  • Review the 2023 list of IAs and determine if you are already performing any activities as part of your normal workflow. If you are reporting an MVP there will be specific IAs available to report as part of the MVP.

  • For traditional MIPS, the number of activities required to maximize MIPS points for this category will depend on the size of the practice and any special status designation. Attesting to more than the required number of activities will not increase your MIPS score. 

    • Small practices attest to 1 high-weighted OR 2 medium-weighted activities

    • Large practices (16 or more) attest to:

      • 2 high-weighted activities; Or

      • 1 high-weighted and 2 medium-weighted activities; Or

      • 4 medium-weighted activities

    • Clinicians and groups with a special status of Non-patient Facing, Health Professional Shortage Area (HPSA) or Rural status attest to 1 high-weighted or 2 medium-weighted activities.

  • For MVPs, participants must select:

    • 2 medium-weighted improvement activities OR 1 high-weighted improvement activity; OR

    • Participates in a certified or recognized patient-centered medical home (PCMH) or comparable specialty practice

  • IA(s) must be attested to for a minimum 90-day reporting period.

  • If reporting as a group, at least 50% of those under the TIN must have completed the activity.

  • Carefully review the suggested documentation for your chosen activities to view what CMS is recommending for each one and ensure you can provide documentation as proof that you completed the activity.

Determine if you can report the Promoting Interoperability (PI) category.

  • Reporting PI requires you to have an electronic health record (EHR) system that is certified to the 2015 Edition Cures Update certification criteria.

  • Run a trial report in your EHR of the 2023 PI measures to understand how you are performing in each area since it will impact your total MIPS score. 

  • PI must be reported for a minimum 90-day reporting period.

  • Small practices (with fewer than 16 clinicians) will have PI automatically reweighted in 2023. This means if a small practice does not report the PI category the Quality category will be weighted at 40% of the final MIPS score, Improvement Activities weighted at 30%, and Cost weighted at 30%.  

STEP 4: Begin your reporting!

MDinteractive provides one-stop shopping for submitting Quality, Promoting Interoperability, and Improvement Activities data to CMS to fulfill all of your reporting requirements. Our support team can help you navigate the annual changes to the MIPS reporting requirements and develop a strategy to maximize your MIPS scores.

Starting your 2023 MIPS reporting early can help you stay ahead of the game, reduce stress, and increase your chances of success in the MIPS program. If you have not already started tracking your Quality data it’s important to get started now since measures must be reported for the entire calendar year. 

  • If you have an electronic health record (EHR) system, ensure that it is up-to-date and able to capture the necessary data for your Quality measures. Upload a test file from your EHR to your MDinteractive account so we can confirm that data is in the correct format.
  • If you don’t have an EHR, you can use the MDinteractive Data Grid to submit patient data or use “Create Patient Record” at the top of your dashboard to manually enter eligible patient records for your measure(s).

Reporting your data on a regular basis will allow you to monitor your progress throughout the year to ensure that you are meeting your MIPS reporting goals and making any necessary adjustments to your reporting strategy. If you notice early on that you are not performing well on a measure(s), you can either implement processes within your practice to improve your performance or consider selecting other measures to report where your performance might be better.

Looking for More Information?

Our MIPS reporting checklist offers important tips on how to get started with your 2023 MIPS reporting. In addition to this checklist, we have many more resources on our website and in our software that you can access by logging into your MDinteractive account.  A little planning goes a long way and can help you avoid costly mistakes down the road. Contact one of our MIPS specialists today to answer any questions and help you get started.

2023 MIPS Reporting 2023 MIPS Checklist

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