How is MIPS Participation Determined?
- Physicians (including doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
- Physician Assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Groups that includes such clinicians
- Clinicians who have billed more than $30,000 in Medicare Part B allowable charges and have more than 100 Part B-enrolled Medicare beneficiaries
- Clinicians who enroll in Medicare for the first time in 2017
- Clinicians who participate in an Advanced APM and are either a Qualifying APM Participant (QP) or Partial QP
- Clinicians who bill Medicare for $30,000 or less
- Clinicians who have provided care for 100 Medicare patients or fewer
- Clinicians who are not in a MIPS-eligible specialty
If you have a certain percentage of your Part B payments through an Advanced APM or see a certain percentage of your patients through an Advanced APM, you will not have to submit data to MIPS.
During the QPP 2017 Performance Period, CMS took three "snapshots" (on March 31, June 30, and August 31) to see which Advanced APM participants met the thresholds to become Qualifying APM Participants (QPs).
If you participate in Advanced APMs, but don't meet the threshold, you may become a Partial QP. Partial QPs can choose if they want to participate in MIPS.
For 2017 (Performance Year 1), your eligibility was reviewed at two different times in the year.
CMS has completed both eligiblity reviews. The first review was completed in December 2016 by examining claims from September 1, 2015 through August 31, 2016. We reviewed Medicare Part B Claims data and PECOS data and will only apply it to 2017 (Performance Year 1).
CMS completed the second review in December 2017. We examined Medicare Part B Claims data from September 1, 2016 through August 31, 2017 and PECOS data. If you joined a new practice during this time period, your eligibility under that practice was evaluated during the second review.
If you are a clinician who bills to Medicare, check to see if you need to submit data to MIPS by simply entering your National Provider Identifier (NPI) number into our tool.Check Now
How is Special Status calculated?
To determine if a clinician's participation should be considered as special status under the Quality Payment Program, CMS retrieves and analyzes Medicare Part B claims data. A series of calculations are run to indicate a circumstance of the clinician's practice for which special rules under the Quality Payment Program (QPP) will affect the number of total measures, activities or entire categories that an individual clinician or group must report. These circumstances are applicable for clinicians in: Health Professional Shortage Area (HPSA), Rural, Non-patient facing, Hospital Based, Small Practices and Ambulatory Surgical Center (ASC).
These tables explain the special status calculations.
Calculations for an individual clinician
|Small practice||The practice that the clinician is billing under has 15 or fewer clinicians.|
|Non-patient facing||The clinician has 100 or fewer Medicare Part B patient-facing encounters (including Medicare telehealth services) during the non-patient facing determination period.|
|HPSA||Practices in areas designated under section 332(a)(1)(A) of the Public Health Service Act.|
|Rural||Practices in zip codes designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data.|
|Hospital based||The clinician furnishes 75% or more of their covered professional services in the inpatient hospital, on-campus outpatient hospital, or emergency room settings (based on place of service codes) during the applicable determination period.|
|ASC||The clinician furnishes 75% or more of his or her covered professional services in sites of service identified by the Place of Service (POS) code 24 used in the HIPAA standard transaction based on claims for a period prior to the performance period as specified by CMS.|
Calculations for a Practice (TIN Level)
|Small practice||The practice has 15 or fewer clinicians billing under the practice.|
|Non-patient facing||The practice has more than 75% of the NPIs under the practice’s TIN meeting the definition of an individual non-patient facing clinician during the non-patient facing determination period.|
|HPSA||The practice has at least one clinician that is designated as Health Professional Shortage Area.|
|Rural||The practice has at least one clinician that is designated as rural.|
|Hospital based||All clinicians associated with the practice are hospital based. If any individual in the group does not meet the hospital based status, the group will not be a hospital based group.|
|ASC||All clinicians associated with the practice are ASC-based. If any individual in the group does not meet the ASC-based status, the group will not be an ASC-based group.|
These calculations are run using the same review periods as used for MIPS participation. If the two calculations to determine any of these special status circumstances differ, the clinician or practice received the special status. The ASC calculations are only run once.
Certified Electronic Health Record Technology (CEHRT) Hardship Exception
For Performance Year 2018, Certified electronic health record technology is required for participation in the Advancing Care Information performance category of the Quality Payment Program (QPP).
Under Merit-based Incentive Payment System (MIPS) scoring, MIPS eligible clinicians and groups may qualify for a reweighting of their Advancing Care Information performance category score to 0 percent of the final score if they meet the criteria outlined. Simply lacking CEHRT does not qualify the MIPS eligible clinician or group for reweighting. Learn more about a Hardship Exception