Exploring MACRA

Female Physician

MIPS Overview

MIPS is an acronym for the Merit-based Incentive Payment System and is a new program that consolidates and sunsets the previous quality programs, including the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and the Electronic Health Records Incentive program (Meaningful Use), into one program.

 MIPS has four performance categories: 

  • Quality (based on PQRS)
  • Advancing care information (replaces the EHR Incentive Program and the meaningful use criteria)
  • Improvement activities (a new category) 
  • Cost (replaces Value Modifier)

The first performance year for MIPS started on January 1, 2017.

A good resource for additional overview information on MIPS: https://qpp.cms.gov/mips/overview


Performance Measures

MIPS eligible clinicians will be subject to payment adjustments to Medicare reimbursements based on an annual assessment in four performance categories – Quality, Cost, Advancing Care Information, and Improvement Activities.

Quality: This category replaces PQRS and assesses quality measures included in the MIPS final list published by November 1 of each year. This includes national specialty society measure sets.  MIPS eligible clinicians must submit data to CMS on six measures that best reflect their practice, including at least one outcome measure, for the full calendar year beginning in the 2018 performance year. Clinicians can select measures individually or report from a specialty specific measure set.

These resources provide guidance for the quality category:

Cost:  This category replaces the VM and calculates performance based on physician spending. For the 2017 transition reporting period, CMS will calculate the Cost category but it will not be factored into the composite score that will determine the payment adjustment in 2019. Cost will comprise 10 percent of the composite score in the 2018 performance year to determine the payment adjustment in 2020. Physicians do not need to report for this category.  CMS uses administrative claims data to assess performance and there is no requirement to submit or report any data. 

Advancing Care Information: This category replaces the EHR Incentive Program and the meaningful use criteria and focuses on “the secure exchange of health information and the use of certified electronic health record technology (CEHRT) to support patient engagement and improved healthcare quality.” MIPS eligible clinicians must attest or report in the following five required measures: 1) security risk analysis; 2) electronic prescribing; 3) provide patient access; 4) send a summary of care; and 5) request/ accept summary of care.  These required measures will first determine a base score that is one of three scores that make up the total Advancing Care Information score. Second, physicians can then choose to submit up to nine measures for an additional performance score. Third, CMS will also award a bonus score for the use of CEHRT to complete certain activities in the improvement activities performance category and for reporting to public health or clinical data registries.

New for 2018, CMS will reweigh the Advancing Care Information performance category to 0 percent from 25 percent and reallocate that 25 percent to the Quality performance category for “special status” MIPS eligible clinicians including 1) hospital based clinicians who deliver 75 percent or more of their Medicare Part B services through a hospital; 2) ambulatory surgical center based clinicians; 3) physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists; and 4) non-patient facing clinicians. These clinicians will be automatically exempted from the Advancing Care Information category and do not need to submit a hardship exception application.

In addition, other MIPS eligible clinicians may apply to obtain an exemption from the Advancing Care Information category for “significant hardship.” Hardships can include insufficient Internet connectivity, extreme and uncontrollable circumstances, lack of control over the availability of CEHRT, clinicians in small practices, or whose EHR was decertified. If CMS grants the exemption, the Advancing Care Information score will be reweighted to 0 percent. MIPS eligible clinicians must submit a Quality Payment Program Hardship Exception application by December 31, 2018.

These resources provide guidance for the advancing care information category:

http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/MIPS-Pathway/ACI%20Category%20Overview.pdf https://qpp.cms.gov/mips/advancing-care-information

Improvement Activities: This is a new category that support “broad aims within healthcare delivery, including care coordination, beneficiary engagement, population management, and health equity.” The inventory of Improvement Activities allows physicians to choose the activities most appropriate to their practices and may largely be activities that physicians already perform and may receive credit.  MIPS eligible clinicians must attest to four medium weighted or two high-weighted activities for a minimum of a continuous 90-day period. This requirement is further reduced to two medium-weighted or one high-weighted activity for small practices (fewer than 15 participants), rural practices, or practices located in geographic health professional shortage areas, and non-patient facing MIPS eligible clinicians. Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model automatically earn full credit in this category. Participants in a non-qualifying MIPS APM will receive half of the total improvement activities score automatically and may report additional activities to receive full credit.

 These resources provide guidance for the advancing care information category:


MIPS applies to Medicare Part B participating “MIPS eligible clinicians.” In 2017 and 2018, eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. In 2019 and beyond, MIPS provides the Secretary of the U.S. Department of Health and Human Services (HHS) with the discretion to broaden the list of MIPS eligible clinicians to include other eligible professionals currently participating in Medicare Part B.

MIPS eligible clinicians do not include clinicians who:

  • Participate in Advanced APMs;
  • Meet a low-volume threshold which is defined as clinicians who 1) have Medicare Part B allowed charges less than or equal to $90,000 OR 2) provide care for 200 or fewer Part B enrolled Medicare beneficiaries; or
  • Are in their first year of Medicare provider enrollment.

Note that for the 2017 performance year, the low volume threshold was less than $30,000 in Medicare allowed charges or 100 or fewer Medicare patients. Physicians who are exempt from MIPS will receive the annual fee schedule increase but are not eligible for positive or negative payment adjustments under MIPS. MIPS does not apply to hospitals or facilities.

Learn more about eligibility here: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/MIPS-Participation-Fact-Sheet-2017.pdf

To check if you need to submit data to MIPS:  https://qpp.cms.gov/mips/individual-or-group-participation


Scoring and Payment

Each performance category is weighted across the four performance categories, which are adjusted over the first three years of the program as follows:

Calculating MIPS Performance Score

For the 2017 transition reporting period, Cost will not be factored into the composite score that will determine the payment adjustment in 2019.

Physicians’ MIPS scores are determined on their overall performance in each of the four MIPS categories compared to the CMS performance threshold score for a given year. Physicians will receive a score in each category, and their MIPS final score will be the sum of the weighted score of each category. If the final score is below the threshold, physicians will receive a negative adjustment of their Medicare Part B payments; if the final score is equal to the threshold, physicians will receive no adjustment of their Medicare Part B payments; and if the final score is above the threshold, physicians will receive a positive adjustment of their Medicare Part B payments.

The potential maximum adjustment, positive or negative, increases every year as follows:

How much can MIPS adjust payments?

Note that these numbers are the maximum up or down adjustment and a clinician’s particular adjustment can fall anywhere within that range. MIPS is designed to be a budget-neutral program, which means that the payment adjustments are determined on a curve, requiring providers to be measured against each other to determine who qualifies for a payment increase or decrease. Physicians also have the potential to receive up to an additional 10 percent bonus, funded from a total annual pool of $500 million, for exceptional performance for payment years 2019 through 2024.

For additional information on MIPS scoring and related payment adjustments:


Physicians can participate in MIPS and report as individuals or as a group. If a physician submits data as an individual, meaning a single NPI that is tied to a single Tax Identification Number (TIN), their payment adjustment will be based on their performance alone. Physicians can also submit data to CMS as a group. The group will get one payment adjustment based on the group’s performance across all four MIPS performance categories. A group means “a single TIN with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their individual NPI, who have reassigned their billing rights to the [group] TIN.

Virtual Group reporting is a new 2018 MIPS participation option.  A virtual group is a combination of two or more TINs assigned to one or more solo practitioners, or to one or more groups consisting of ten (10) or fewer clinicians (including at least one (1) MIPS eligible clinician), or both, that elect to form a virtual group for a performance period for a year.  According to CMS, solo practitioners or groups with ten (10) or fewer eligible clinicians may not have enough cases to be reliably measured on their own, but together they could increase the performance volume in order to be reliably measured. In addition, the formation of virtual groups provides shared responsibility and an opportunity to effectively and efficiently coordinate resources to achieve requirements under each performance category. 

To participate in a virtual group, solo practitioners must be a MIPS eligible clinician who exceeds the low-volume threshold. Such solo practitioners may not be a newly Medicare-enrolled MIPS eligible clinician, a Qualifying APM Participant (QP), or a Partial QP choosing not to participate in MIPS. For groups to participate in a virtual group, they must have: 1) ten (10) or fewer clinicians; 2) at least one (1) MIPS eligible clinician; and 3) exceed the low-volume threshold at the group level.  Solo practitioners or groups of ten (10) or fewer eligible clinicians must submit an election to participate in MIPS as a virtual group by December 31 of the calendar year prior to the start of the applicable performance period.  Elections cannot be changed once the performance period begins. Virtual group participants may elect to be in no more than one virtual group for a performance period and, in the case of a group, the election applies to all MIPS eligible clinicians in the group. Each MIPS eligible clinician in the virtual group will receive a MIPS payment adjustment based on the virtual group's combined performance assessment, unless the MIPS eligible clinicians are also in a MIPS APM in which case the MIPS payment adjustment for these eligible clinicians is based solely on their APM Entity score.

These resources provide more information on Virtual Groups:



Individuals and groups may elect to submit their MIPS data for the quality, improvement activities, or advancing care information performance categories using the following mechanisms:

  • A qualified registry which is defined as “a medical registry, a maintenance of certification program operated by a specialty body of the American Board of Medical Specialties or other data intermediary that, with respect to a particular performance period, has self-nominated and successfully completed a vetting process (as specified by CMS) to demonstrate its compliance with the MIPS qualification requirements specified by CMS for that performance period”;
  • EHR submission mechanism, which includes submission of data by health IT vendors or other authorized providers on behalf of the MIPS eligible clinician;
  • A qualified clinical data registry (QCDR) that has been approved by CMS to collect medical and clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients; and
  • Attestation for improvement activities and advancing care information performance categories.

MIPS eligible clinicians submitting data as an individual can also send data for the quality performance category through routine Medicare Part B claims.

Groups comprised of 25 or more MIPS eligible clinicians can also send data for all three performance categories through a CMS web interface. To submit data through the CMS Web Interface for the 2018 performance year, the group must register with CMS between April 1 and June 30, 2018.

MIPS eligible clinicians and groups may submit information via multiple mechanisms, however, the same identifier for all performance categories must be used and they may only use one submission mechanism per performance category.

MIPS eligible clinicians and groups must submit data by March 31 following the end of the performance period.

This resource provides guidance on the different MIPS reporting mechanisms available: