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About MIPS Participation

Your participation status may change each Performance Year (PY) due to shifting requirements. As the Quality Payment Program continues to move towards full program implementation, CMS realizes it can be hard for small practices to participate so we continue to offer tailored flexibility for groups of 15 or fewer clinicians.

Check your participation status to see which changes to QPP might affect you and your practice.

How is 2017 MIPS Participation Determined?

Clinicians Included in MIPS

  • 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 include one or more of the clinician types above.

If you're included in MIPS for Performance Year 2017, you will need to decide whether to report as an individual or group. Read more about this choice.

Clinicians Exempt from MIPS

  • Clinicians who are not one of the clinician types above
  • 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 are not in a MIPS eligible specialty
  • Clinicians or groups that have billed $30,000 or less in Medicare Part B allowable charges
  • Clinicians or groups that provided care for 100 or fewer Part B-enrolled Medicare beneficiaries

If you're exempt from MIPS for Performance Year 2017, you won't need to do anything for MIPS for the year.

Clinicians Participating in Advanced APMs

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 will take three "snapshots" (on March 31, June 30, and August 31) to see which Advanced APM participants meet 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.

Review Periods

For MIPS, your eligibility will be reviewed at two different times during the Performance 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.


Check Your Participation Status

Enter your National Provider Identifier (NPI) number.


How is 2017 Special Status Calculated?

Special Status

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.

2017 Calculations for an individual MIPS eligible clinician

Special statusDescription
Small practiceA clinician associated with a practice that has 15 or fewer clinicians [National Provider Identifiers (NPIs)] billing under the a single Taxpayer Identification Number (TIN). Small practices must attest to the size of the practice.
Non-patient facingThe clinician has 100 or fewer Medicare Part B patient-facing encounters (including Medicare telehealth services) during the non-patient-facing determination period, during one of the segments of the 24-month non-patient-facing determination period (September 1, 2015 - August 31, 2016 or September 1, 2016 - August 31, 2017).
HPSAThe clinician practices in an area designated under section 332(a)(1)(A) of the Public Health Service Act.
RuralThe clinician practices in a zip code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data.
Hospital basedThe clinician furnishes 75% or more of his or her covered professional services identified by the Place of Service (POS) codes used in the HIPAA standard transaction as an inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room settings (POS 23), based on an analysis of claims data during a 12-month determination period (September 1, 2015 - August 31, 2016).

2017 Calculations for a Practice (TIN Level)

Special statusDescription
Small practiceA group that has 15 or fewer clinicians (NPIs) billing under the group’s TIN. Small practices must attest to the size of the practice.
Non-patient facingA group is considered non-patient-facing if more than 75% of the clinicians (NPIs) billing under the group’s TIN meet the definition of a non-patient-facing individual MIPS eligible clinician during one of the segments of the 24-month non-patient facing determination period (either September 1, 2015 through August 31, 2016 or September 1, 2016 through August 31, 2017).
HPSAA group that has at least one practice site under its TIN designated as a HPSA is considered to be a HPSA practice.
RuralA group that has at least one practice site under its TIN in a zip code designated as a rural area is considered to be rural.
Hospital based

100% of the MIPS eligible clinicians associated with the practice are designated as hospital-based during one of the two determination periods. If any MIPS eligible clinician in the group does not meet the individual hospital-based criteria, the group will not be designated as hospital-based.

Note: This group level calculation is limited to MIPS eligible clinicians who exceeded the low-volume threshold as individuals.
ASC

100% of the MIPS eligible clinicians associated with the practice are designated as ASC-based. If any MIPS eligible clinician in the group does not meet the individual ASC-based criteria, the group will not be designated as ASC-based.

Note: This group level calculation is limited to MIPS eligible clinicians who exceeded the low-volume threshold as individuals, are not new Medicare-enrolled eligible clinicians, and do not have a Qualifying APM Participant (QP) status.

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 MIPS eligible clinician (NPI) or practice (TIN) will receive the special status. The ASC calculations are only run once.

Certified Electronic Health Record Technology (CEHRT) Hardship Exception

Don’t have Certified Electronic Health Record Technology? You can apply for a Hardship Exception if you do not have Certified Electronic Health Record Technology (CEHRT). 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 Exception Applications

How is 2018 MIPS Participation Determined?

Clinicians Included in MIPS

  • 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 or virtual groups that include one or more of the clinician types above

If you're included in MIPS for Performance Year 2018, you will need to decide whether to report as an individual or group. Read more about this choice.

Clinicians Exempt from MIPS

  • Clinicians who are not one of the clinician types above
  • Clinicians who enroll in Medicare for the first time in 2018
  • Clinicians who participate in an Advanced APM and are either a Qualifying APM Participant (QP) or Partial QP
  • Clinicians who are not in a MIPS eligible specialty
  • Clinicians or groups that have billed $90,000 or less in Physicial Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare secondary Payer)
  • Clinicians or groups that have 200 or fewer Medicare Part B FFS beneficiaries

If you're exempt from MIPS for Performance Year 2018, you are not required to participate. However, you are encouraged to check your participation status again if you've made any changes that may change your eligibility status.

Clinicians Participating in Advanced APMs

For Performance Year 2018, 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 Performance Year, CMS will take three "snapshots" (on March 31, June 30, and August 31) to see which Advanced APM participants meet 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.

Review Periods

For Performance Year 2018, your eligibility will be reviewed at two different times during the Performance Year.

Review Dates

For Performance Year 2018, the first review was completed in December 2017 by examining claims from September 1, 2016 through August 31, 2017. We reviewed Medicare Part B Claims data and PECOS data and will only apply it to PY 2018.

CMS will complete the second review in late 2018. We will examine Medicare Part B Claims data from September 1, 2017 through August 31, 2018 and PECOS data. If you joined a new practice during this time period, your eligibility under that practice will be evaluated during the second review.


Check Your Participation Status

Enter your National Provider Identifier (NPI) number.


How is 2018 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)-based.

These tables explain the special status calculations.

2018 Calculations for an individual MIPS-eligible clinician

Special statusDescription
Small practiceA clinician associated with a practice that has 15 or fewer clinicians [National Provider Identifiers (NPIs)] billing under the practice’s Taxpayer Identification Number (TIN) during the small practice size determination period (September 1, 2016 - August 31, 2017 with a 30-day claims run out).
Non-patient facingThe clinician has 100 or fewer Medicare Part B patient-facing encounters (including Medicare telehealth services) during the non-patient-facing determination period, during one of the segments of the 24-month non-patient-facing determination period (September 1, 2016 - August 31, 2017 or September 1, 2017 - August 31, 2018).
HPSAThe clinician is associated with a practice that is in an area designated under section 332(a)(1)(A) of the Public Health Service Act.
RuralThe clinician is associated with a practice that is in a zip code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data.
Hospital-basedThe clinician furnishes 75% or more of his or her covered professional services identified by the Place of Service (POS) codes used in the HIPAA standard transaction as an inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room settings (POS 23), based on an analysis of claims data during a 12-month determination period (September 1, 2016 - August 31, 2017).
ASC-basedThe clinician furnishes 75% or more of his or her covered professional services in sites of service identified by Place of Service (POS) code 24, used in the HIPAA standard transaction based on claims filed during a 12-month determination period (September 1, 2016 - August 31, 2017).

2018 Calculations for a Practice (TIN Level)

Special statusDescription
Small practiceA group that has 15 or fewer clinicians (NPIs) billing under the group’s TIN during the small practice size determination period (September 1, 2016 - August 31, 2017 with a 30-day claims run out).
Non-patient facingA group is considered non-patient facing if more than 75% of the clinicians (NPIs) billing under the group’s TIN meet the definition of a non-patient-facing individual MIPS eligible clinician during one of the segments of the 24-month non-patient facing determination period (September 1, 2016 - August 31, 2017 or September 1, 2017 - August 31, 2018).
HPSAA group that is in an area designated under section 332(a)(1)(A) of the Public Health Service Act and with multiple practices under its TIN will be designated as an HPSA practice if more than 75% of the NPIs billing under the group’s TIN are designated as an HPSA.
RuralA group that is in a zip code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data and has multiple practices under its TIN will be designated as a rural practice if more than 75% of the NPIs billing under the group’s TIN are designated in a zip code as a rural area.
Hospital-based

100% of the MIPS eligible clinicians associated with the group are designated as hospital-based during a 12-month determination period (September 1, 2016 - August 31, 2017). If any MIPS eligible clinician in the group does not meet the individual hospital-based criteria, the group will not be designated as hospital-based.

Note: This group level calculation is limited to MIPS eligible clinicians who exceeded the low-volume threshold as individuals, are not new Medicare-enrolled eligible clinicians, and do not have a Qualifying APM Participant (QP) status.
ASC-based

100% of the MIPS eligible clinicians associated with the group are designated as ASC-based during a 12-month determination period (September 1, 2016 - August 31, 2017). If any MIPS eligible clinician in the group does not meet the individual ASC-based criteria, the group will not be designated as ASC-based.

Note: This group level calculation is limited to MIPS eligible clinicians who exceeded the low-volume threshold as individuals, are not new Medicare-enrolled eligible clinicians, and do not have a Qualifying APM Participant (QP) status.

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 will receive the special status. For the 2017 Performance Year, the ASC calculation was 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 Promoting Interoperability (formerly 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 Promoting Interoperability (formerly 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 Exception Applications