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The Centers For Medicare And Medicaid Services (CMS) Established The Quality Payment Program (QPP) As Required By The Medicare Access And CHIP Reauthorization Act Of 2015 (MACRA). The Act Repealed The Sustainable Growth Rate Formula And Changed The Way Medicare Reimburses Physicians, Stressing Value Over Volume.

Merit-Based Incentive Payment System (MIPS): An Overview

This is the first in a series reviewing the Merit-based Incentive Payment System and Alternative Payment Models by MedData’s Senior VP of Medical Affairs.

The Centers for Medicare and Medicaid Services (CMS) established the Quality Payment Program (QPP) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The act repealed the Sustainable Growth Rate formula and changed the way Medicare reimburses physicians, stressing value over volume.

Multiple quality programs were streamlined under the Merit-based Incentive Payment System (MIPS). In addition, bonus payments were established for participation in eligible Alternative Payment Models (APMs). The goals of the programs are to reward high-value, high-quality clinicians participating in Medicare with payment increases, while at the same time reducing payments to those clinicians who do not meet Medicare’s benchmarks for performance standards.

There are two ways to take part in the quality payment program: Merit-based incentive payment system or advanced APMs.
Image source: CMS “2019 MIPS Quick Start Guide”


Clinician performance is measured in four categories: Quality, Improvement Activities, Promoting Interoperability, and Cost. Essentially, Merit-Based Incentive Payment System (MIPS) consolidates a number of previous programs including: EHR Incentive Programs, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM). The program performance year is from Jan. 1 to Dec. 31. The data for any particular year is submitted the following year and affects the payments for the year after. For example, data for performance year 2018 must be submitted by March 31, 2019, and affects payments beginning Jan. 1, 2020.

  • The Quality measure replaces PQRS. In 2019, CMS is making continued efforts to create and support quality measures that are valuable indicators of the quality of care that is delivered rather than just another hoop clinicians have to jump through. The QPP has developed specialty sets that assist in choosing those measures that are specific to a particular practice. In general, six measures are chosen, and the clinician’s scores on those measures are attributed to the final score. For Performance Year 2019, Quality represents 45% of the final score.
  • Improvement Activities includes an inventory of activities that are designed to assess how well clinicians enhance patient engagement, increase access to care, and improve overall care processes. For 2019, there are 118 listed activities on the QPP website. In order to earn full credit in this category, participants are required to submit a combination of activities that include: two high-weighted activities; one high-weighted activity and two medium-weighted activities; or 4 medium-weighted activities. Each activity must be performed for 90 or more continuous days in 2019. For Performance Year 2019, Improvement Activities represents 15% of the final score.
  • The Promoting Interoperability category focuses on patient engagement and the electronic exchange of health information through the use of certified electronic health record technology (CEHRT) replacing Meaningful Use. The QPP site provides 39 measures. Participants must submit collected data from four objectives for 90 continuous days or more for 2019. For Performance Year 2019, Promoting Interoperability represents 25% of the final score.
  • The Cost category replaces VBM. The QPP looks at two measures including total per capita cost (TPCC) and Medicare spending per beneficiary (MSPB) for the year, or during a hospital stay, and/or during 8 episodes of care. Cost measures are calculated automatically through claims data. For Performance Year 2019, Cost represents 15% of the final score.

Clinicians Eligible for Merit-Based Incentive Payment System

For 2019, MIPS-eligible clinicians include:

  • Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
  • Osteopathic practitioners
  • Chiropractors
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians or nutrition professionals

Low-Volume Threshold

In order for a clinician or a group to be excluded for 2019, the low-volume threshold includes three specific characteristics:

  • Bill $90,000 or less in Medicare Part B-allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), or
  • Provide covered professional services for 200 or fewer Part B-enrolled individuals, or
  • Provide 200 or fewer covered professional services to Part B-enrolled individuals

In order to be excluded, a clinician or group must meet one of the above aspects of covered professional services. If a clinician or group meets any of these criteria, they are not required to participate in Merit-Based Incentive Payment System.


Even though a clinician or group may be excluded, there are advantages to participating including opportunities for bonus points and payments. In order to opt-in, an eligible clinician or group must exceed at least one, but not all three, of the low-volume threshold criteria.

Small Practice Bonus

The small practice bonus is increased to 6 points and will now be added to the Quality performance category, rather than in the MIPS final score calculation.

Complex Patients Bonus

Apply an adjustment of up to 5 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. Generally, this will award between 1 to 5 points to clinicians based on the medical complexity of the patients they see.


For 2019, there are a number of ways a clinician or group can collect and submit Quality and Improvement Activity measures. The type of measures collected include: eCQMs, MIPS Clinical Quality Measures (MIPS CQMs), Quality Clinical Data Registry (QCDR) measures, Medicare Part B claims measures, CMS Web Interface measures, the CAHPS for MIPS survey, and administrative claims measures.

Deciding on which submitter type and which submission type you will use to report is important. Small practice status affects the options for MIPS reporting. Small practices still can use Claims Based reporting to submit quality measures data, although this is not a requirement, and can use a registry or QCDR. Practices that do not meet the low-volume threshold will need to consider various options for submission including a Quality Registry such as MedData’s Clinical Registry (available on clients’ My MedData page) or various QCDRs.

Payment Adjustments

Hospital-Based Clinicians: Clinicians who provide 75% of their covered professional services in off-campus outpatient hospital, inpatient hospital, on-campus outpatient hospital, or emergency room settings (as identified by place of service (POS) codes 19, 21, 22, 23) during a determination period are considered hospital-based. Hospital-based clinicians and groups are still required to participate in MIPS but qualify for automatic reweighting of the Promoting Interoperability performance category to 0% of the final score. This is redistributed, increasing the weight of the Quality score to 70%.

Non-patient Facing Clinicians: Clinicians who bill 100 or fewer patient-facing encounters (including Medicare telehealth services) during a determination period are considered non-patient facing. A group is considered non-patient facing if more than 75 percent of its clinicians have 100 or fewer patient-facing encounters (including Medicare telehealth services). Non-patient facing clinicians and groups are required to participate in MIPS but have reduced data submission requirements for the Improvement Activities performance category and qualify for automatic reweighting of the Promoting Interoperability performance category to 0% of the final score. The PI score is redistributed, increasing the weight of the Quality score to 70%.

For 2019, eligible clinicians’ MIPS performance will determine whether they receive a positive or negative payment adjustment of up to 7 percent on their 2021 Medicare reimbursements for covered professional services. These payment adjustments are prospectively applied to each claim beginning Jan. 1, 2021. Note that payment adjustments are budget neutral.

In the next installment of this series, I will drill down on specific specialties, discuss their individual Quality Measures and Improvement Activities and the actions that can be taken to improve the probability of a positive payment adjustment. In the interim, I would suggest exploring the QPP website.

This Post Has One Comment

  1. We were disappointed in the MACRA MIPS incentive payments. But, we would be doing the quality improvement work anyway. And we use Medcurity for the Security Risk Analysis, so that’s easy to manage. Submitting the data was OK through the EHR – only a couple hiccups.

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