{"id":8704,"date":"2019-05-15T13:29:00","date_gmt":"2019-05-15T07:59:00","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=8704"},"modified":"2025-09-10T09:45:19","modified_gmt":"2025-09-10T09:45:19","slug":"what-is-mips-and-how-it-affects-my-practice","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/what-is-mips-and-how-it-affects-my-practice\/","title":{"rendered":"What is MIPS and How it Affects My Practice?"},"content":{"rendered":"

What is MIPS?<\/strong><\/h2>\n

On November 1, 2018, CMS released revisions to payment policies under the Medicare Part B physician fee schedule for the Quality Payment Program (QPP) for the calendar year 2019. In accordance with one of the most bipartisan and significant legislative changes to Medicare in a generation, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the legacy Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with the QPP, a new value-based reimbursement system impacting Part B payments to clinicians nationally. The QPP rule is updated at least once per year and consists of two major tracks:<\/p>\n

    \n
  1. The Merit-based Incentive Payment System (MIPS)<\/li>\n
  2. Alternative Payment Models (APMs)<\/li>\n<\/ol>\n

    For the 2019 performance year, CMS predicts that 800,000 Part B clinicians will be subject to MIPS. MIPS is effectively the \u201cnew default\u201d for Part B where clinicians are excluded from MIPS only under certain conditions.<\/p>\n

    Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician<\/a> Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.<\/p>\n

    Who is subject to MIPS?<\/strong><\/h2>\n

    MIPS eligibility includes only those eligible clinicians in the categories below who bill for Medicare Part B (otherwise known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH. The eligibility net includes these professionals: Physicians (MD\/DO and DMD\/DDS), Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Physical and Occupational Therapists, Speech-Language Pathologists, Audiologists, Clinical Psychologists, and Registered Dietitians or Nutrition Professionals.<\/p>\n

    Exclusions from MIPS<\/strong><\/h2>\n
      \n
    • Clinicians in their first calendar year of Medicare Part B participation<\/li>\n
    • \u201cLow-volume exclusion\u201d: in a 12-month period, clinicians or groups each (a) billing $90,000 or less in Medicare Part B allowed charges for services, (b) providing care for 200 or fewer Part B beneficiaries, or (c) delivering 200 or fewer covered services to Part B beneficiaries<\/li>\n
    • Clinicians in entities sufficiently participating in an Advanced APM<\/li>\n<\/ul>\n

      How is it going to affect my practice?<\/strong><\/h2>\n

      The Merit-based Incentive Payment System (MIPS) is one of the two payment tracks created under MACRA; the other is the Advanced Alternative Payment Model (AAPM) track. MIPS adjusts payment based on performance in four performance categories:<\/p>\n

        \n
      • Quality \u2013 based on the Physician Quality Reporting System (PQRS) (45%)<\/li>\n
      • Cost \u2013 based on the Value-based Payment Modifier (VBPM) (15%)<\/li>\n
      • Promoting Interoperability (PI) \u2013 based on the Medicare EHR Incentive Program (Meaningful Use) (25%)<\/li>\n
      • Improvement Activities \u2013 a new category (15%)<\/li>\n<\/ul>\n\n\n\n\n\n\n\n
        Performance Category<\/strong><\/td>\n2019<\/strong><\/td>\n2020<\/strong><\/td>\n2021<\/strong><\/td>\n<\/tr>\n
        Quality<\/td>\n45%<\/td>\n40%**<\/td>\n35%**<\/td>\n<\/tr>\n
        Cost<\/td>\n15%<\/td>\n20%**<\/td>\n25%**<\/td>\n<\/tr>\n
        Promoting Interoperability<\/td>\n25%*<\/td>\n25%*<\/td>\n25%*<\/td>\n<\/tr>\n
        Improvement Activities<\/td>\n15%<\/td>\n15%<\/td>\n15%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        *If the Secretary of the U.S. Department of Health and Human Services (HHS) determines the proportion of eligible clinicians who are \u201cmeaningful users of electronic health records (EHRs)\u201d is estimated at 75% or greater, the weight of the PI category may be reduced. The remaining performance categories will be increased by the corresponding number of percentage points. The lowest weight the PI category can carry is 15%.<\/p>\n

        **Anticipated category weights<\/strong><\/h3>\n

        The MIPS payment adjustment amount will be determined based on an eligible clinician or group\u2019s MIPS Final Score, which can be a maximum of 100 points. In 2017, the payment adjustments and associated MIPS Final Scores will be as follows:<\/p>\n\n\n\n\n\n\n\n
        MIPS Final Score<\/strong><\/td>\nPayment Adjustment<\/strong><\/td>\n<\/tr>\n
        \u2265 70 points<\/td>\nPositive adjustment
        Eligible for the exceptional performance bonus, which means at least an additional 0.5%<\/td>\n<\/tr>\n
        4-69 points<\/td>\nPositive adjustment
        Not eligible for exceptional performance bonus<\/td>\n<\/tr>\n
        3 points<\/td>\nNeutral payment adjustment<\/td>\n<\/tr>\n
        0 points<\/td>\nNegative payment adjustment of -4%
        0 points mean an eligible clinician did not participate<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        The exceptional performance bonus is an annual pool of $500,000,000 incentive dollars that are allocated to eligible clinicians who are part of the top tier of MIPS participants in a given performance year. Only MIPS participants (individual clinicians or groups) are eligible for the exceptional performance bonus.<\/p>\n\n\n\n\n\n\n\n\n\n
        PERFORMANCE YEAR<\/strong><\/td>\nMEDICARE PART B PAYMENT ADJUSTMENT YEAR<\/strong><\/td>\nMAXIMUM -% MIPS PENALTY<\/strong><\/td>\nMAXIMUM +% MIPS BASE INCENTIVE<\/strong><\/td>\nMAXIMUM +% MIPS EXCEPTIONAL PERFORMANCE BONUS<\/strong><\/td>\n<\/tr>\n
        2017<\/td>\n2019<\/td>\n-4%<\/td>\n+4%*X
        (Actual 0.29%)<\/td>\n        		+10%*Y
        (Actual 1.59% )<\/td>\n<\/tr>\n
        2018<\/td>\n2020<\/td>\n-5%<\/td>\n+5%*X
        (CMS predicts 0.30% )<\/td>\n        		+10%*Y
        (CMS predicts 1.75% )<\/td>\n<\/tr>\n
        2019<\/td>\n2021<\/td>\n-7%<\/td>\n+7%*X
        (CMA predicts 1.11%)<\/td>\n        		+10%*Y
        (CMS predicts 3.58%)<\/td>\n<\/tr>\n
        2020<\/td>\n2022<\/td>\n-9%<\/td>\n+9%*X<\/td>\n+10%*Y<\/td>\n<\/tr>\n
        2021<\/td>\n2023<\/td>\n-9%<\/td>\n+9%*X<\/td>\n+10%*Y<\/td>\n<\/tr>\n
        2022<\/td>\n2024<\/td>\n-9%<\/td>\n+9%*X<\/td>\n+10%*Y<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        Performance is measured through the data clinicians report in four areas – Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. We designed MIPS to update and consolidate previous programs, including Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).<\/p>\n

        (Source<\/strong>: Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System webinar. November 29, 2016.)<\/p>\n

        FAQs<\/strong><\/h2>\n\n\n
        1. What is MIPS in the context of Medicare?<\/strong>

        The Merit-based Incentive Payment System (MIPS) is part of the Quality Payment Program (QPP) established under MACRA, adjusting Medicare Part B payments based on clinician performance across various quality measures.<\/p> <\/div>

        2. Who is eligible for MIPS?<\/strong>

        MIPS includes eligible clinicians such as physicians, nurse practitioners, and other healthcare professionals who bill for Medicare Part B services. Exclusions apply to new participants, low-volume providers, and those in Advanced Alternative Payment Models (APMs).<\/p> <\/div>

        3. What performance categories are assessed under MIPS?<\/strong>

        MIPS evaluates clinicians based on four categories: Quality (45%), Cost (15%), Promoting Interoperability (25%), and Improvement Activities (15%). These weights may change annually, affecting payment adjustments.<\/p> <\/div>

        4. How does MIPS affect payment adjustments for clinicians?<\/strong>

        Clinicians earn an MIPS Final Score based on their performance, which determines payment adjustments. Scores of 70 or above result in positive adjustments, while lower scores may lead to penalties.<\/p> <\/div>

        5. What is the exceptional performance bonus in MIPS?<\/strong>

        The exceptional performance bonus is an additional incentive for top MIPS participants, funded by a pool of $500 million, rewarding those who score particularly high in performance metrics.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"

        What is MIPS? On November 1, 2018, CMS released revisions to payment policies under the Medicare Part B physician fee schedule for the Quality Payment Program (QPP) for the calendar year 2019. In accordance with one of the most bipartisan and significant legislative changes to Medicare in a generation, the Medicare Access and CHIP Reauthorization […]<\/p>\n","protected":false},"author":2,"featured_media":20370,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[4042,1599,3865],"class_list":["post-8704","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-alternative-payment-models","tag-merit-based-incentive-payment-system","tag-mips"],"yoast_head":"\nMBC: What is MIPS and How it Affects My Practice?<\/title>\n<meta name=\"description\" content=\"The MIPS payment adjustment amount will be determined based on an eligible clinician, which can be a maximum of 100 points.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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