MIPS 2020 Final Rule Now Available - What Does it Mean for You?

Posted on November 4, 2019

The Centers for Medicare and Medicaid Services (CMS) has released its Final Rule for the Quality Payment Program (QPP), with several changes to MIPS in 2020 and future reporting years. The Final Rule continues to gradually increase the reporting requirements under the MIPS program. In this article we will highlight the most important changes you need to know for the 2020 performance year and how they could impact your bottom line. We will also cover how CMS plans to transform the program in 2021 to reduce your reporting burden.

Higher Performance Thresholds and Penalties

CMS increases the performance threshold, which is the number of MIPS points needed to avoid any penalties, to 45 MIPS points in 2020 (up from 30 points in 2019) and 60 MIPS points in 2021. Additionally, the exceptional performance threshold to achieve a bonus will increase from 75 MIPS points in 2019 to 85 MIPS points in 2020 and 2021.

There will also be greater financial implications for MIPS eligible clinicians who choose not to report. The maximum penalty for not reporting in 2020 will rise to negative -9% (up from -7% this year). While payment adjustments would range from -9% to +9%, any positive payment adjustments are expected to be below 9% due to the federal budget neutrality requirements.

Performance Categories 

Category Weights

All of the MIPS category weights remain the same in 2020:

QualityCostPromoting InteroperabilityImprovement Activities




*CMS noted that it is not finalizing changes to the Quality and Cost performance category weights for the 2021 performance period at this time, but will make proposals for updating these in next year’s rulemaking process.


The data completeness requirements will increase from 60% to 70% beginning in 2020. This means Quality measures will need to be reported on at least 70% of eligible cases, for both Medicare and non-Medicare patients, for the entire year. Measures that are submitted, but do not meet the data completeness threshold (even if they have a measure benchmark and/or meet the 20 case minimum), would receive 0 points (instead of 1 point in 2019). Clinicians in small practices (15 or less in the TIN) would continue to receive 3 points for measures that don’t meet the data completeness requirements.

Additional changes include:

  • Removing or topping out several Quality measures.
  • Adding new specialty sets for Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietician, and Endocrinology.
  • Establishing flat percentage benchmarks for limited cases where CMS determines that the measure’s benchmark could potentially incentivize inappropriate treatment for some patients.

Promoting Interoperability (PI)

CMS is not proposing any significant changes to the PI category in 2020. The Final Rule will consider a group as hospital-based and eligible for reweighting if more than 75% of the clinicians in the group meet the definition of a hospital-based individual MIPS eligible clinician (it is currently 100%).

Additional changes include:

  • Beginning with the 2019 performance period, CMS will:
    • Allow clinicians to satisfy the optional Query of Prescription Drug Monitoring Program (PDMP) measure with a yes/no response instead of a numerator/denominator;
    • Redistribute the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if an exclusion is claimed.
  • Beginning with the 2020 performance period, CMS will remove the Verify Opioid Treatment Agreement measure and keep the Query of PDMP measure as optional.

Improvement Activities (IA)

CMS increases the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice for the Improvement Activities category.

Additional changes include:

  • Modifying the definition of rural area to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP Code file available.
  • Updating the IA inventory and establishing criteria for removing activities in the future.
  • Concluding the CMS Study on Factors Associated with Reporting Quality Measures.
  • Removing criteria for Patient-Centered Medical Home designation that a practice must have received accreditation from one of 4 accreditation organizations that are nationally recognized or comparable specialty practice that has received the NCQA Patient-Centered Specialty Recognition.


CMS will add 10 new episode-based measures to the Cost category and revise the current measures – Medicare Spending Per Beneficiary Clinician measure and Total Per Capita Cost measure.  There will be no changes to current case minimum requirements.

MIPS Value Pathways (MVP)

CMS will adopt a new framework to transform the MIPS program beginning with the 2021 performance year called the MIPS Value Pathways. The agency stated that under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs). The goal of MVPs is to move towards an aligned set of measures more relevant to a clinician’s scope of practice across all MIPS performance categories for different specialties or conditions.

CMS created some illustrative diagrams regarding the MIPS Value Pathways:

MIPS Value Pathways Diagram

MIPS Value Pathways Surgery Example 

MIPS Value Pathways Diabetes Example

Looking Ahead

MIPS eligible clinicians and groups should continue to stay on top of their 2019 MIPS data reporting, but become familiar with the changes for the 2020 reporting year. The QPP Final Rule will establish higher performance thresholds and payment adjustments next year, so more reporting and planning will be necessary to avoid any penalties.  

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MACRA 2020 MIPS Final Rule MIPS Reporting MIPS Value Pathway

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