Overview
The traditional Merit-based Incentive Payment System (MIPS) is the original reporting option available to for collecting and reporting data to MIPS. The quality performance category evaluates the quality of care you deliver by measuring health care processes, outcomes, and patient experiences of care.
Requirements may change each due to policy changes.
Select Performance Year
Performance Year
Select your performance year.
2024 Performance Year Quality Requirements
30% OF FINAL SCORE
This percentage can change due to special statuses, exception applications, or Alternative Payment Model (APM) Entity participation.
This page provides an overview of quality requirements for traditional MIPS. For information regarding the quality requirements for the MIPS Value Pathways (MVPs) reporting option, visit Explore MVPs. To learn more about quality requirements under the APM Performance Pathway (APP), visit Quality: APP Requirements.
What Quality Data Should I Submit?
MIPS Quality Measure Data
You must collect and submit measure data for the 12-month performance period (January 1 - December 31, 2024).
There are 5 collection types for MIPS quality measures:
- (eCQMs);
- MIPS Clinical Quality Measures (CQMs);
- Qualified Clinical Data Registry (QCDR) Measures;
- Medicare Part B Claims Measures; and
- The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey.
General reporting requirements are as follows:
- You’ll need to submit collected data for at least 6 quality measures (including one outcome measure or high priority measure in the absence of an applicable outcome measure), or a complete specialty measure set.
- New for 2024: Beginning with the 2024 performance period, you’ll need to report performance data for at least 75% of the denominator eligible cases for each quality measure (data completeness), which is an increase from the previous data completeness threshold of 70%.
- You can submit measures from different collection types to fulfill the requirement to report data for at least 6 quality measures.
We’ll automatically calculate and score 4 administrative claims measures for individuals, groups, virtual groups, and APM Entities when such measures are applicable and if the individuals, groups, virtual groups, or APM Entities meet the requirements to be scored on the measure. The following are the 4 administrative claims measures automatically calculated and scored.
- Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups. (This measure is only applicable to groups and virtual groups).
- Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS).
- Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions.
- Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure under MIPS
Specialty Measure Sets
If you choose to submit data for a specialty measure set, you must submit data on at least 6 quality measures within that set. If the specialty measure set contains fewer than 6 quality measures, you must submit data for each quality measure in the set.
CAHPS for MIPS Survey Measure
If a group, virtual group, or APM Entity participating in traditional MIPS registers for the CAHPS for MIPS Survey and meets the sampling requirements to administer the CAHPS for MIPS Survey, this measure may count as 1 of the 6 minimum required quality measures. Registration for the CAHPS for MIPS Survey is between April 1, 2024, and July 1, 2024.
New: Beginning in the 2024 performance period, registered groups, virtual groups, and APM Entities are required to contract with a CAHPS for MIPS Survey vendor to administer the Spanish translation of the survey to Spanish-preferring patients.
We also recommend that groups, virtual groups, and APM Entities administer the other available translations of the CAHPS for MIPS Survey (Cantonese, Korean, Mandarin, Portuguese, Russian, and Vietnamese) based on the language needs of their patients.
How Should I Submit Data?
There are 3 submission types you can use for quality measures. The submission types are:
- Medicare Part B Claims (small practices only);
- Sign In to the QPP Website and Upload; and
- Direct Submission via QPP Submission (API)
Determine which submission type is best for you based on how you intend to submit data (as a MIPS eligible clinician, group, virtual group, or APM Entity).
As a MIPS eligible clinician, you have the following options available to you:
Number of Clinicians in Practice | Medicare Part B Claims | Sign In and Upload | Direct Submission (API) |
15 or fewer | |||
16 or more |
As a representative of a group, virtual group, or APM Entity, you have the following options available to your group, virtual group, or APM Entity:
Number of Clinicians in Group, Virtual Group, or APM Entity | Medicare Part B Claims | Sign In and Upload | Direct Submission (API) |
15 or fewer | |||
16-24 | |||
25 or more |
As a , you have the following options available to you:
Medicare Part B Claims | Sign In and Upload | Direct Submission (API) |
Aggregation of Data Using an Electronic Health Record (EHR)
If you transition from one system to another during the performance period, you’ll need to aggregate the data from the previous EHR system(s) and the new EHR system into one report for the full 12-month performance period prior to submitting the data.
If your group uses multiple EHR systems for clinicians billing as a group under the same Taxpayer Identification Number (TIN), virtual group uses multiple EHR systems for TINs associated with the virtual group, or APM Entity uses multiple EHR systems for TINs participating in the APM Entity, you’ll need to aggregate data across the multiple EHR systems into a single report prior to submitting the data. If a situation arises where data for the full 12 months is unavailable (for example, data aggregation from two or more EHR systems isn't possible due to a transition of EHR systems), you should submit as much quality data as possible. However, we want to emphasize that the 12-month performance period and 75% data completeness threshold continue to be applicable reporting requirements regardless of an EHR transition during the performance period.
If you're submitting eCQMs using multiple EHR systems, the submitting EHR system must be certified to align with the Office of the National Coordinator for Health IT (ONC)’s regulations at 45 CFR 170.315 for the 2024 performance period.
How Are Measures Scored?
We determine measure achievement points by comparing performance on a measure to a measure benchmark.
If a measure can be reliably scored against a benchmark, it means:
- A benchmark is available;
- Case minimum criteria has been met (measure had a submission of at least 20 cases (for most measures)); and
- Data completeness criteria has been met (performance data reported for at least 75% of the denominator eligible patients/cases).
Bonus Points
Bonus points are only available for small practices. Six bonus points will continue to be added to the quality performance category score for clinicians in small practices who submit at least one measure, either individually or as a group, virtual group, or APM Entity. This bonus isn’t added to clinicians, groups, or virtual groups who are scored under facility-based scoring.
Quality Improvement Score
Individual MIPS eligible clinicians, groups, virtual groups, and APM Entities may earn up to 10 additional percentage points based on their improvement in the quality performance category from the previous year.
When Will Facility-Based Measures Scoring Apply?
Facility-based scoring may be applied to facility-based clinicians, groups, and virtual groups. APM Entities aren’t eligible to receive facility-based status.
Facility-based scoring will be used for your quality and cost performance category scores when all the following conditions are met:
- You’re identified as facility-based;
- You’re attributed to a facility with a FY 2025 Hospital Value-Based Purchasing (VBP) Program score (we won’t know this until the end of the 2024 performance period); and
- The facility-based scoring methodology using your Hospital VBP Program score results in a higher final score than your final score calculated without the application of facility-based measurement.