This page describes how your MIPS eligibility status is determined. To view your eligibility status, use the QPP Participation Status Tool. You can also learn more about your reporting options and how other reporting factors might impact your requirements.
The way we determine eligibility may change each
Performance Year
Select your performance year.
2024 MIPS Eligibility
Your eligibility status is based on your:
- National Provider Identifier (NPI) and
- Associated Taxpayer Identification Numbers (TINs).
A TIN can belong to:
- You, if you’re self-employed,
- A practice, or
- An organization like a hospital.
When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination.
If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations.
We evaluate each TIN/NPI combination for MIPS eligibility and use TINs to evaluate practices for eligibility.
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Low-Volume Threshold
The low-volume threshold includes 3 aspects of covered professional services:
- Allowed charges.
- Number of Medicare patients who receive covered professional services.
- Number of services provided.
You exceed the low-volume threshold if you:
- Bill more than $90,000 for Medicare Part B covered professional services, and
- See more than 200 Medicare Part B patients, and
- Provide more than 200 covered professional services to Medicare Part B patients.
MIPS Determination Period
We review past and current Medicare Part B claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each performance year. Each review, or “segment,” analyzes a 12-month period.
- After the first 12-month segment, we release preliminary eligibility.
- After the second 12-month segment (reconciled with the first segment), we release final eligibility determinations.
Clinicians who are otherwise eligible are required to participate in MIPS if they exceed the low-volume threshold as an individual during both segments of the MIPS Determination Period.
- Exception: Eligibility will be based solely on segment 2 data when a TIN or TIN/NPI combination is newly established during segment 2 of the MIPS Determination Period.
MIPS Eligible Clinician Types
You're eligible to participate in MIPS if you're a MIPS eligible clinician type and you also meet all the other requirements in the next section. If you’re not one of the clinician types listed below, you’re excluded from reporting and the MIPS payment adjustment:
- 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
- Clinical social workers
- Certified nurse midwives
MIPS Eligible Clinicians
A clinician can be individually eligible or eligible at the group level. Your eligibility status determines whether you’ll receive a MIPS payment adjustment.
An individually eligible clinician is required to participate in MIPS.
- These clinicians will receive a MIPS payment adjustment regardless of data submission.
A clinician who’s only eligible at the group level will receive a MIPS payment adjustment when:
- Their practice chooses to participate in MIPS as a group or as part of a CMS-approved virtual group .
- They participate in a subgroup and submit data for a MIPS Value Pathway (MVP).
- They’re part of a MIPS APM and their APM Entity reports to MIPS.
Learn more about what to do next as a MIPS eligible clinician.
MIPS Eligible Clinicians in a MIPS APM
Clinicians who participate in MIPS APMs are evaluated for MIPS eligibility at the individual and group level, just like any other clinician. These clinicians have the option of reporting traditional MIPS, the APM Performance Pathway (APP), or a MIPS Value Pathway (MVP).
Opt-in Eligible Clinicians and Groups
Opt-in eligible clinicians and groups exceed 1 or 2, but not all 3, elements of the low-volume threshold. If you’re opt-in eligible, then you aren't required to participate in and report to MIPS, but during the submission period, you may elect to opt-in to MIPS.
Opt-in eligible clinicians and groups can report traditional MIPS or the APM Performance Pathway (APP). Opt-in eligible clinicians and groups can’t report an MVP for the 2024 performance year.
If you elect to opt-in, you’ll:
- Be considered a MIPS eligible clinician and be required to report data to MIPS,
- Receive performance feedback,
- Receive a MIPS payment adjustment (positive, negative, or neutral),
- Be eligible to have your data publicly reported on the Doctors and Clinicians section of Care Compare (formerly “Physician Compare”), and
- Be assessed in the same way as MIPS eligible clinicians who are required to participate in MIPS.
Voluntary Reporting (Traditional MIPS Only)
You can voluntarily report traditional MIPS as an individual or group in the following circumstances:
- You (individual or group) are opt-in eligible and elect to voluntarily report.
- You (individual or group) are exempt from MIPS (neither eligible nor opt-in eligible).
You can’t voluntarily report if you’re eligible for MIPS.
You can’t voluntarily report the APP or an MVP.
If you voluntarily report traditional MIPS, you’ll:
- Receive limited performance feedback, allowing you to prepare for future years, and;
- Be eligible to have your data published on the Doctors and Clinicians section of Care Compare (formerly “Physician Compare”).
If you voluntarily report to MIPS, you:
- Won't receive a MIPS payment adjustment based on the data submitted, or
- Won't be included in the calculation of MIPS measure benchmarks.
Qualifying APM Participants (QPs)
If you sufficiently participate in an Advanced APM Entity, you may achieve QP status, which excludes you from MIPS participation. If you don't achieve QP status and are otherwise considered a MIPS eligible clinician, you'll need to participate in MIPS. Clinicians who achieve Partial QP status only need to participate in MIPS if they (or their APM Entity) submit an election to do so.
We'll make QP determinations using each Advanced APM Entity’s Participation List at 3 snapshot dates: March 31, June 30, and August 31.
What Might Cause My Eligibility to Change?
Reason | Details |
---|---|
Joining a New Practice or APM Entity | You may be required to report to MIPS if you bill Medicare Part B claims under a new practice/TIN in segment 2 of the MIPS Determination Period or join an APM Entity in later snapshots. |
Changing Provider Type/Specialty Code from Segment to Segment | Changing your provider type or specialty code from segment to segment of the determination period could affect your eligibility. |
Billing Data for Segment 1 but not Segment 2 | If you stop billing Medicare Part B claims under a specific practice (TIN) during segment 1, and have no Medicare Part B claims billed during segment 2 for that practice, you'll be removed entirely from the practice’s list of connected clinicians. |
Falling below the Low-Volume Threshold in MIPS Segment 2 | You won't be eligible to participate if you fall below all 3 elements of the low-volume threshold in segment 2 of the MIPS Determination Period. Learn more about APM Determination Periods |
Dropping out of an APM Entity during the Performance Year | We assess eligible clinicians for QP Status at the APM Entity level, based on either the payment amount or patient count method. We assess an eligible clinician for QP status individually only when the Advanced APM Entity includes an eligible clinician on an Affiliated Practitioner List, or when the eligible clinician participates in multiple Advanced APM Entities and doesn't achieve QP status at the APM Entity level. Calculations for eligible clinicians on an Affiliated Practitioner List will be published each snapshot. Individual QP scores will be calculated for those in more than one APM Entity; the most favorable of the scores will be published as part of the third snapshot results. You'll maintain your QP status unless the Advanced APM Entity’s participation in the Advanced APM is voluntarily or involuntarily terminated prior to the end of the QP performance period. |
Changing QP Status | Your QP status can change at each APM snapshot depending on whether the APM Entity or individual score meets or exceeds the QP thresholds. A clinician doesn't need to attain QP status at each of the 3 snapshots. If a clinician achieves QP status at any snapshot, the clinician will maintain their QP status for the performance year. Learn more about APM Determination Periods |