The Merit-based Incentive Payment System (MIPS) is continually evolving, making it increasingly challenging for eligible clinicians to optimize their scores. Although the minimum performance threshold for 2024 remains at 75 points, reaching this goal requires meticulous planning and strategy. Our 2024 MIPS checklist offers essential tips to help you stay ahead of the game and achieve the best possible outcomes.
2024 MIPS Reporting Checklist
Step 1: Review your 2024 MIPS eligibility status: Are you required to report MIPS in 2024?
| 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 2024, 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 2024 eligibility status. The tool will tell you:
- If you are required to report MIPS for any practice(s) in 2024
- 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 (2025).
MIPS eligibility status should be checked again at the end of 2024 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, 2023 - September 30, 2024, 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, 2024. | 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):
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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.
*Note there is no requirement to report MIPS as a group.
Step 3: Develop Your Reporting Plan: Will you report traditional MIPS or an MVP?
| 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, including 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 2024, 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 December 2nd, 2024, 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 2024 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 75% of eligible encounters (up from 70% in 2023), 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 2024 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 a certified electronic health record (EHR) that meets the Office of the National Coordinator for Health Information Technology (ONC) criteria.
Run a trial report in your EHR of the 2024 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 180-day reporting period in 2024 (up from 90 days in 2023).
Small practices (with fewer than 16 clinicians) will have PI automatically reweighted in 2024. 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 2024 MIPS reporting early can help you stay ahead, reduce stress, and boost your chances of success. If you haven’t begun tracking your Quality data yet, it’s crucial to start now, as measures need to be reported for the entire calendar year. Regular data reporting will enable you to monitor your progress throughout the year, ensuring you meet your MIPS goals and adjust your strategy as needed. If you identify performance issues with certain measures early on, you can either improve your practice processes or select alternative measures where you may perform better.
Looking for More Information?
Our MIPS reporting checklist offers important tips on how to get started with your 2024 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.
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