MIPS Reporting Options

Understand factors that Influence MIPS Reporting as Individuals, Group, and Virtual Group 

Eligibility and Special Status 


A quick overview of the MIPS eligibility criteria 

ELIGIBLE CLINICIANS


The following clinicians are covered under MIPS 2018 provided they exceed the Low Volume Threshold at the individual or group level (if reporting as a group), are not newly enrolled in Medicare, and do not qualify as QP or partial QP under an Advanced APM: 


Doctors of Medicine (MD)

Doctors of Osteopathy (DO)

Doctors of Dental Surgery/Dental Medicine (DMD/DDS)

Doctors of Podiatry (DPM)

Doctors of Optometry (OD)

Chiropractors (DC)

Physician Assistants (PA)

Nurse Practitioners (NP)

Clinical Nurse Specialists (CNS)

Certified Registered Nurse Anesthetists (CNA)

LOW VOLUME THRESHOLD


The low volume threshold to determine if the clinician types included in MIPS need to report, has two components. Both parts of the threshold must be crossed for a clinician to be included in MIPS. That is, the eligible clinicians must bill more than $90,000 in Medicare Part B allowed charges for services only AND provide care to more than 200 Medicare Part B beneficiaries. If an eligible clinician doesn’t meet both the criteria, s/he is exempt from MIPS. 


Following the Bipartisan Budget Act of 2018 (HR 1892) enacted on Feb 9, 2018, the charges for Medicare Part B drugs will not be included in the low volume threshold determination or the application of payment adjustment for performance year 2018. 

SPECIAL STATUS DEFINITIONS


Clinicians meeting the following status have been granted some special considerations under MIPS.  

Non-Patient-Facing (NPF) Clinician

An individual MIPS eligible clinician who bills 100 or fewer patient-facing encounters (including Medicare telehealth services). 


Health Professional Shortage Areas (HPSAs)

Health Professional Shortage Areas (HPSAs) are areas designated by Health Resource Service Administration as having shortages of primary medical care, dental or mental health providers and may be geographic , demographic or institutional. 


Small Practice

Practices consisting of 1-15 eligible clinicians 

Clinicians can pick a different submission method for each performance category, but ONE reporting option must be chosen for all performance categories.


If a practice chooses to report for Quality performance category as a group, the practice would need to report as a group for ACI, IA, and Cost as well. 

Individuals, Groups, and Virtual Groups


A Comparison of MIPS Requirements - Determining MIPS Eligibility & MIPS Submissions

INDIVIDUAL SUBMISSIONGROUP SUBMISSIONVIRTUAL GROUP SUBMISSION
DefinitionSingle NPI tied to a
single TIN
Set of clinicians (identified by NPIs) sharing a TIN

Different TINs (individual MIPS eligible clinician or a group of 10 or fewer clinicians) coming together with at least one other such TIN to form a Virtual Group.

Exceed Volume Threshold To be able to submit as individuals, the MIPS eligible clinician has to exceed the volume threshold at the individual NPI level. To be able to submit as groups, the group has to exceed the volume threshold at the TIN level.

The TIN must include at least 2 or more eligible clinicians, and at least 1 MIPS eligible clinician, as identified by the NPI.
Each participating TIN in a Virtual Group
has to exceed the volume threshold at the TIN level.

So, the solo practitioners participating would need to exceed the volume threshold, and a group will need to exceed the volume threshold as a group. 
Qualifying for NPF and HPSA StatusNeed to satisfy the criteria for a Non-Patient-Facing (NPF) or Health Professional Shortage Areas (HPSAs) at the individual level to earn the status >75% of the clinicians in the group need to meet the criteria for NPF, HPSA for the group to earn that status. >75% of the clinicians in the virtual group need to meet the criteria for NPF, HPSA to earn that status.
Submission MethodsEHR, Registry or a Qualified Clinical Data Registry and Claims

(Claims only available to individuals)
EHR, Registry or a Qualified Clinical Data Registry and CAHPS for MIPS survey

CMS Web Interface available to groups of 25 or more

For groups of 16 or more an additional quality measure - 30 Day All-Cause Hospital Readmission Measure may be applicable. 
All the submission method options and policies for groups apply to
Virtual Groups too. 
Data Submission At individual NPI level Aggregated data at the TIN level for each measure.

The performance of non-MIPS eligible clinician types, the new Medicare-enrolled clinicians, the QPs and Partial QPs can also be included. 
Aggregated data for all NPIs under each TIN within the virtual group for each measure.

Virtual Group Identifier will be required submit MIPS data.

Rules for data inclusion same as for the group data submission. 
MIPS Score
Calculation
MIPS score calculated for each NPI/TIN separately, even though they may be part of one group. One MIPS score will apply to all the MIPS eligible clinicians in the group.

No MIPS score will be assigned to non-MIPS eligible clinician types, and the new Medicare-enrolled clinicians. 
Same scoring policies as groups.
Payment AdjustmentPayment adjustment will apply to the NPI/TIN in the payment year 2020 based on the MIPS score earned in 2018. The payment adjustment will only apply to all the MIPS eligible clinicians in the group.

If some clinicians have multiple MIPS scores (group score and the MIPS-APM score), the payment adjustment will be applied according to the following hierarchy:
1. MIPS-APM score
2. Virtual Group Score
3. Group Score

Payment adjustments will NOT be applied to the Medicare payments in 2020 for the clinicians who didn’t have a MIPS score in 2018.

Thus, non-MIPS eligible clinician types and the new Medicare-enrolled clinicians will NOT receive a MIPS payment adjustment. 
The payment adjustment will only apply to all the MIPS eligible clinicians in the group.

The MIPS-APM score will take precedence over the Virtual Group score for Clinicians who are also participating in a MIPS-APM.

Thus, clinicians participating in MIPS-APM and Virtual Group will receive payment adjustment according to their MIPS-APM score, even if it is lower than the Virtual Group MIPS Score.

Payment adjustments will NOT be applied to the Medicare payments in 2020 for the clinicians who didn’t have a MIPS score is assigned in 2018.

Thus, non-MIPS eligible clinician types and the new Medicare-enrolled clinicians will NOT receive a MIPS payment adjustment.  

MIPS Submission Methods


Access Quick Start Guide for MIPS Submission Methods and the Impact on the Performance Categories 

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