New in 2019
The rules and requirements have changed each year of the MIPS program. Here is a list of the major modifications from previous years. More information about these topics can be founded in the referenced section:
- Facility-based scoring (Quality and Cost)
- Opt-in (Eligibility)
- Three low-volume threshold criteria (Eligibility)
- Promoting interoperability overhaul (Promoting Interoperability)
- Multiple submission types allowed within a performance category (Quality)
- Claims submission can only be utilized by small practices (Submission Mechanisms)
- Removal of normal dose limits quality measure (Quality)
Eligibility
Physicians can look up eligibility on the QPP Participation Lookup tool based on their National Provider Identification (NPI) number.

MIPS applies to clinicians billing more than $90,000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare Part B enrolled patients a year AND more than 200 Medicare Part B covered services. Billing and patient volumes are based on 12-month historical data (September-August). The new requirements allow for physicians to opt-in to MIPS if they meet at least 1 of the 3 criteria. Those opting in will receive the related payment adjustment 2 years later. Those that do NOT meet any of the criteria can voluntarily report data; however, they will not receive a payment adjustment.

Eligible clinicians include:
- Physicians
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- NEW Registered dietician or nutrition professional
- NEW Physical therapists
- NEW Occupational therapists
- NEW Qualified speech-language pathologists
- NEW Qualified audiologists
- NEW Clinical psychologists
Participation
There are many requirements and rules in MIPS, however there is still a large amount of flexibility for participating in the program.
Program Goals
The level of participation in the MIPS program is dependent on the practice’s financial goals. There is a different level of effort if a practice wants to achieve 30 points to avoid the 7 percent penalty or achieve more points to receive a larger payment adjustment. In this budget-neutral program, the funds collected from the penalties will be utilized to pay for the positive payment adjustments. If an individual or group achieves over 75 points, they will be eligible for the exceptional performance bonus, funded through a separate source. Having a goal in mind prior to determining the remainder of the participation elements is key.

As the Performance Threshold increases year to year, it is harder to avoid the penalty. In 2019, practices must submit data from more than one performance category to achieve 30 points.
Individual vs Group vs Virtual Group
There are three reporting options for MIPS based on TIN/NPI combination. The decision to report as an individual, group or virtual group is part of your MIPS strategy and will be unique to your practice.
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Individual
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Group
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Virtual Group
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Definition
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A single NPI tied to a single TIN
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A single TIN. All NPIs who have assigned their billing rights to a single TIN would be part of this group
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A physician or group of less than 10 that has joined with another similar group (regardless of specialty)
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Impact on Payment Adjustment
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Your performance will directly impact your payment adjustment
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A group’s performance is assessed across all of the MIPS performance categories and the group will get one payment adjustment based on the group’s performance
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A Virtual Group’s performance is assessed across all of the MIPS performance categories and the virtual group will get one payment adjustment based on the virtual group’s performance
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Data Submission
MIPS provides several data submission options, and most are available for Quality, Improvement Activities and the Promoting Interoperability performance categories. Beginning in 2019, data can be submitted via multiple mechanisms within a performance category. For example, a physician can utilize a registry to report some quality measures and claims to report others. If the same measure is submitted via multiple mechanisms, the one with the greatest number of measure achievement points will be selected for scoring.
In 2019, only small practices (≤15 eligible clinicians) can use Claims for data submission. It’s not an option if you’re participating in MIPS as a large group. Claims data is only available for the Quality performance category. If you choose to submit quality data through claims, Quality Data Codes (QDCs) will need to be added to denominator eligible claims to show that the required quality action occurred, or exclusion applied. QDCs are specified Current Procedure Terminology (CPT) II codes (with or without modifiers) and G-codes used for submission of quality data for MIPS. When these codes are included on your claims form, it identifies your selected quality measures for CMS. You’ll also need to apply encounter codes, including ICD-10-CM, CPT Category I, or Healthcare Common Procedure Coding System (HCPCS) codes. These codes show which patients should be added toward the denominator/numerator of the quality measure.
A Registry is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. Each registry is different; however, most will collect data for the Quality, Improvement Activities and Promoting Interoperability performance categories. A full list of CMS-approved entities can be found on the CMS website.
A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. The QCDR reporting option is different from a Registry because it is not limited to quality measures within MIPS. The QCDR can develop and submit QCDR measures for CMS consideration and approval. The QOPI Reporting Registry is available for radiation oncology and medical oncology practices. See a full list of the 2019 measures. The QOPI Reporting Registry collects and reports data for the Quality, Improvement Activities and Promoting Interoperability performance categories.
An Electronic Health Record (EHR) can provide two ways to submit data to CMS. Either the vendor can submit MIPS data to CMS on your behalf or the vendor can provide the clinician with a Quality Reporting Document Architecture (QRDA) file which you can submit on your own through the CMS Portal. The capability and available options are vendor specific, so please check with your EHR vendor to understand the available options. CMS approves EHR data submission for Quality, Improvement Activities and Promoting Interoperability performance categories.
The
CMS Portal is a secure internet-based data submission mechanism available for all physicians and groups. To sign into the
CMS portal, you will need your Enterprise Identity Management (EIDM) credentials and have the appropriate user role associated with your organization. The EIDM login is the same login used during PQRS submission. Password reminders and registration for new users can be found on the QPP webpage. You will be able to report as either a group or individual for each TIN associated with the account. Attestation is available for the Improvement Activities and Promoting Interoperability performance categories. For the Quality performance category, users will be able to import an approved data file.
Bonus
The 2019 performance year includes two bonus opportunities. Both were introduced during the 2018 performance year; however, one has been modified for 2019:
- Small Practice Bonus – MODIFIED - 6 points - Practices comprised of 15 or less eligible clinicians will automatically receive this bonus in the numerator of the Quality performance category score.
- Complex Patient Bonus – up to 5 points – CMS will automatically calculate and award this bonus based on two indicators:
- Medical complexity as measured through Hierarchical Condition Category (HCC) risk scores*, and
- Social risk as measured through the proportion of patients with dual eligible† status.
The bonus will be calculated by adding the HCC Score, capped at 3-points, and the dual eligible ratio, multiplied by 5. You do not need to submit any additional information for CMS to be awarded this bonus.
*HCC Risk Score is a payment methodology based on risk used by CMS to adjust payments at the patient level. This means that 2 patients within the same community can have a different payment rate based on several factors relating primarily to the amount of risk—or work—it takes to maintain the health of a patient. In the 2018 QPP proposed rule, CMS stated that the average HCC score for radiation oncology is 1.79.
†Dual Eligible refers to beneficiaries qualifying for both Medicare and Medicaid benefits
. CMS has stated that the average dual eligible ratio for radiation oncology is 22.2 percent.
Sample Calculations
General Equation: HCC + (Dual Eligible Ratio x 5) = Complex Patient Bonus
Using CMS radiation oncology averages: 1.79 + (0.22 x 5) = 2.89 Complex Patient Bonus Points
Each practice will have its own unique combination of indicators based on the population it serves and are capped at 5 points.