Merit-based Incentive Payment System (MIPS)

The rules and requirements have changed each year of the MIPS program. Below is a list of major highlights for the new year:

• Increased performance period for Promoting Interoperability to a minimum of 180 days.
• Addition of Tobacco Use quality measure to radiation oncology measure set.
• Payment adjustment is +/-9%.
• Performance threshold remains at 75 points.

Physicians can look up eligibility on the QPP Participation Lookup tool based on their National Provider Identification (NPI) number.

You’re considered a MIPS eligible clinician (i.e., required to report) and will receive a payment adjustment when:

• You’re an eligible clinician type AND
• You enrolled in Medicare before January 1, 2023 AND
• You’re not identified as a QP AND
• You exceed the low-volume threshold.

To exceed the low-volume threshold for the 2023 performance year, you must:

• Bill more than $90,000 for Part B covered professional services under the Physician Fee Schedule (PFS), AND
• See more than 200 Medicare Part B patients, AND
• Furnish more than 200 covered professional services to Part B Medicare Patients.

These requirements allow for physicians to opt-in to MIPS if they meet at least one of the three criteria. Those opting in will receive the related payment adjustment two years later. Those that do NOT meet any of the criteria can voluntarily report data; however, they will not receive a payment adjustment.

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.

There are many requirements and rules in MIPS, however there is still a large amount of flexibility for participating in the program.

Traditional MIPS, established in the first year of the Quality Payment Program, is the original reporting option available to MIPS eligible clinicians for collecting and reporting data to MIPS. Your performance is measured across 4 areas: quality, improvement activities, promoting interoperability, and cost.  

In addition to traditional MIPS, two other MIPS reporting frameworks, designed to reduce reporting burden, are available to MIPS eligible clinicians.

The APM Performance Pathway (APP), designed to reduce reporting burden, creates new scoring opportunities for participants in MIPS APMs, and encourages participation in APMs. This reporting option is available to MIPS eligible clinicians identified on an APM Participation List or Affiliated Practitioner List of an APM Entity participating in any MIPS APM on any of the four snapshot dates (March 31, June 30, August 31, and December 31) during a performance year.

MIPS Value Pathways (MVPs) are the newest reporting option to fulfill MIPS reporting requirements. To begin preparing, review the steps below. There are 16 MVPs available for reporting in the 2024 performance period. Learn more.

If you choose to submit a specialty measure set, you must submit data on at least six measures within that set. If the set contains fewer than six measures, you should submit each measure in the set. The Radiation Oncology Specialty Measure Set includes four measures with the 2023 addition of Tobacco Use.

CMS determines measure achievement points by comparing performance on a measure to a measure benchmark.

If a measure can be reliably scored against a benchmark, it means:

• A benchmark is available;
• Case minimum criteria has been met (measure had a submission of at least 20 cases (for most measures)); and
• Data completeness criteria has been met (performance data reported for at least 75% of the denominator eligible patients/cases).

One clinician type and several special status designations result in automatic reweighting. These clinicians, groups, virtual groups, and APM Entities are exempt from reporting Promoting Interoperability data for the 2024 performance year:

• Clinician type: clinical social workers
• Special status: ambulatory surgical center (ASC)-based, hospital-based, non-patient facing, and small practice (Note: small practice is the only special status available to APM Entities.)

Individuals, groups, and virtual groups may submit a MIPS Promoting Interoperability Performance Category Hardship Exception application, citing one of the following reasons for review and approval:

• MIPS eligible clinician using decertified EHR technology (decertified under the ONC Health IT Certification Program)
• Insufficient internet connectivity
• Extreme and uncontrollable circumstances
• Lack of control over the availability of CEHRT

If your hardship exception is approved, the Promoting Interoperability performance category will receive a weight of 0% when calculating your final score and the 25% will be redistributed to another performance category (or categories) unless you submit data for the Promoting Interoperability performance category. Learn more.

For the 2024 performance year, you’re required to use an Electronic Health Record (EHR) that meets the certification criteria at 45 CFR 170.315 for participation in this performance category to align with the Office of the National Coordinator for Health Information Technology (ONC)’s current and future regulation.

Clinicians must submit collected data for certain measures from each of the objectives (unless an exclusion is claimed) for the same 180 continuous days (or more) during 2024. 

More information on the specific measures can be found on the CMS website.

There are over one hundred activities to choose from in 2024. How activities are weighted is an important factor in determining the score and how best to satisfy the minimum requirements. For a full list of the activities, visit CMS’s QPP website.

While only attestation of activity completion is necessary for reporting, practices should maintain documentation to demonstrate consistent and meaningful engagement within the performance period. In the event of an audit, documentation must be presented.

RO-ILS: Radiation Oncology Incident Learning System^®, sponsored by ASTRO and AAPM, is a part of Clarity PSO, a federally listed patient safety organization, which meets the requirement for the “Participation in an AHRQ-listed patient safety organization" activity. There is no fee to participate in RO-ILS, but the facility must sign an agreement with Clarity PSO so start the contracting process now. Join the more than 800 facilities enrolled in RO-ILS.

ASTRO’s APEx - Accreditation Program for Excellence focuses on a culture of quality and safety, as well as patient-centered care. Evidence Indicators required for APEx Accreditation map to 15 different improvement activities. The APEx Self-Assessment can satisfy all the requirements for the Improvement Activities Performance Category.

To earn full credit in this performance category, you must generally submit one of the following combinations of activities:

• Two high-weighted activities,
• One high-weighted activity and two medium-weighted activities, or
• Four medium-weighted activities.

High-weighted activities receive 20 points and medium-weighted activities receive 10 points. There is a maximum of 40 points that can be earned from attesting to activities in this performance category.

You’ll receive double points for each high- or medium-weighted activity you submit if you’re an individual clinician, group, virtual group, or APM Entity that holds a qualifying special status. You can check for any special status by signing in to qpp.cms.gov. Small status designation for APM Entities will be displayed in mid-2024.

There are 29 cost measures available for the 2024 performance period, including:

• Episode-based cost measures based on a range of procedures, acute inpatient medical conditions, and chronic conditions, and
• Population-based cost measures focused more broadly on primary and inpatient care.

Radiation oncology practices may be scored on the Medicare Spending per Beneficiary cost measure, but typically are not unless they are large practices that meet the necessary patient counts for inclusion.

Episodes will be attributed to the clinician who provided the Part A and Part B services to a beneficiary during the admission.

• Clinicians who do not see patients in the hospital will not be attributed to any episodes and not scored on the measure.
• Clinicians must be attributed to at least 35 cases to be scored on the measure.

Learn more.

You'll be evaluated and scored on each cost measure for which you meet or exceed the established case minimum. CMS determines measure achievement points by comparing performance on a measure to a performance period benchmark. CMS calculates cost measure benchmarks using performance data from the performance period, rather than historical data.

You must meet the established case minimum for and be scored on at least one measure to receive a cost performance category score.

Facility-Based Scoring

Facility-based scoring may be applied to facility-based clinicians, groups and virtual groups.
Facility-based scoring will be used for your quality and cost performance category scores when all the following conditions are met:

• You’re identified as facility-based.
• You’re attributed to a facility with a fiscal year 2024 Hospital Value-Based Purchasing (VBP) Program score.
• The facility-based scoring methodology using your Hospital VBP Program score results in a higher final score than your final score calculated without the application of facility-based measurement.