Understanding MIPS

What is MIPS?

Under the Medicare Access & CHIP Reauthorization Act of 2015, also known as MACRA, healthcare providers are incentivized to move away from legacy scoring frameworks in favor of new reporting measures that support value-based care.

A big part of the move to value-based care under MACRA is the Merit-based Incentive Payment System, or MIPS, which helps clinics replace fee-for-service payments and focus on compensation linked to quality and value.  

Starting in 2017, MIPS takes the place of Physician Quality Reporting System, Value-Based Modifier, and Meaningful Use of electronic health records programs. Instead of three separate programs, MIPS is one cohesive program with a single score for each physician or group.

The MIPS score is derived from four key components:

Quality is the most important category right now, as it accounts for 60% of the clinician’s overall score.

Each clinician under the MIPS program receives a final score (from 1 to 100) and that number determines the amount of payment the clinician is eligible to receive in 2019. Providers need to score above 3 to avoid negative payment adjustments.

The newest component, Improvement Activities, is intended to give physicians credit for their efforts to reduce disparities in care, engage patients in shared decision-making, and other activities designed to improve care.

Who is eligible to participate in MIPS?

To participate if MIPS, a provider must be part of Medicare Plan B and meet the following requirements:

    1. A provider must be a physician, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse, or anesthetist.
    1. A provider must not be in the first year of Medicare Part B participation.
    1. A provider’s Medicare billing charges must be more than $10,000 and s/he must provide care for more than 2100 Medicare patients in year.
    1. A provider cannot be a hospital or facility.
    2. A provider can be in an Advanced APM but must have enough payments or patients to qualify.

Beginning in year three of the program, provider eligibility will expand to include occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and nutritional specialists.

How Does MIPS Work?

Step one: determine if you will report as an individual provider or as a group. If clinicians participate as a group—defined by CMS as two or more clinicians)—they will be assessed as a group across all four MIPS performance categories.

Each provider’s composite score (1 to 100) will be compared to a performance threshold that consist of the mean or median of the composite performance scores for all MIPS-eligible providers during a period prior to the performance period. When a provider’s composite score registers above the threshold, the provider receives a positive payment adjustment; inversely, when a provider’s composite score falls below the threshold, the provider receives a negative payment adjustment.

To be successful under MIPS and avoid negative payment adjustments, providers must become familiar with the new scoring measures and how they work. There are four performance categories that combine to make up a provider’s composite score, which ultimately determines the level of compensation from CMS.


This category replaces the PQRS and Quality portion of the Value Modifier, and it now accounts for 60% of your composite MIPS score.

Clinicians choose six quality measures from among 271 available to report to CMS that best fit their practice. One measure must be an outcome measure or high-priority measure and one must be a cross-cutting measure. It’s not mandatory to choose six measures, but CMS encourages participating in at least three to four.

Each year the Secretary of Health and Human Services (HHS) publishes a list of quality measures included in the MIPS program. Quality measures typically include activities like reporting on effective clinical care, patient safety, community/population health, and communication and care coordination. Clinicians can also opt for specific quality measures that may look at the percentage of the patient population between ages 50 and 75 who had colorectal cancer screenings, for example. Another specific measure might look at the percentage of patients 65 or older (with a history of falls) who had a risk assessment performed in the previous 12 months.

CMS has been receptive to provider feedback and has already added more than 40 episode-specific measures to MIPS to address input and concerns from specialists that the legislation didn’t originally include – measures that accurately reflect the types of care they provide.


This category replaces the Physician Value-Based Modifier program and it accounts for 0% of your composite MIPS score in the first year.

CMS’s goal for developing cost measures is to provide actionable information that is useful to clinicians and, together with the other components of the MIPS program, drive lowered costs and improved patient outcomes.

For the 2017 reporting period, this category makes up zero percentage of the final score, and reporting is not required. However when you do report, CMS will assess the data from Medicare claims and report on how your performance measures up, even though it will not affect 2019 payments.

Improvement Activities

This is the new category available under MIPS and it accounts for 15% of your composite MIPS score.

Physicians and practices will choose from among 90 practice-improving activities designed to measure capabilities in areas such as care coordination, beneficiary engagement, emergency preparedness and response, and patient safety and practice assessment. Examples of activities under patient safety may include assessing medication adherence or ensuring proper reconciliation of medications from more than one pharmacy.

Attesting to one improvement activity for 90 days counts as a Test. Partial and Full means attesting to at least four medium-weighted activities or a combination of one or two high-weighted activities and a remainder of medium-weighted activities.  

Advancing Care Information (ACI)

This category replaces Meaningful Use and accounts for 25% of your composite MIPS score. The program has been reworked to offer a base score and a performance score. There are two measures to choose from based on your clinic’s use of certified EHR technology (either the 2014 or 2015 edition).

Clinicians report key measures of information exchange, as well as security and interoperability, i.e. how well their records communicate with those of other offices and stakeholders in the system. To score well on this measure, ensuring that your EHR system communicates well with others and has appropriate security measures in place.

It’s interesting to note here that CMS will reweight the Advancing Care Information performance category to zero for Hospital-based clinicians, non-patient facing clinician, nurse practitioner, physician assistant, certified registered nurse, or clinical nurse specialist. This means the 25 points move over to the Quality category, making quality measure worth 85% of your composite MIPS score.

MIPS Quality Measures

Given that quality makes up the majority of your composite MIPS score, it pays to focus intently on this area. You can choose from 271 quality measures that are broken down by priority level, data submission method, and medical specialization. For example, if you are a practicing urologist who wants to report EHR data on High Priority Measures, you’d search the Quality Payment Program website and find:

  1. Closing the Referral Loop: Receipt of Specialist Report
  2. Documentation of Current Medications in the Medical Record
  3. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

On the other hand, if you’re a practicing cardiologist in the MIPS program, and you want to report Claims data on High Priority Measures, you’re search and find:

  1. Care Plan
  2. Controlling High Blood Pressure
  3. Documentation of Current Medications in the Medical Record

The 271 quality measures are meant to fit the needs of your individual practice.

How Centricity Makes MIPS Easier

Reporting is at the heart of MIPS, and accurate, timely, easy to produce reports are the center of Virence’s Centricity Practice Solution. You improve what you measure, and you can rely on Quatris Healthco’s experience in clinics, our ability to service the software and provide the related consulting services that deliver bottom line results.

Whatever area of medical specialization and whichever quality measures you choose to pursue under MIPS, Quatris Healthco will help structure your workflows to produce the desired data for MIPS reporting. For instance, a provider who decides to attest to “Documentation of Current Medications in the Medical Record” will want to utilize Centricity’s EMR functionality, and the additional functionality found in DenialsIQ, Comprehensive Financial Reporting, Clinical Quality Reporting and/or Quality Submission Service.

Clinical Quality Reporting is Virence’s cloud-based reporting tool for QPP attestation. With CQR in place you can capture your clinic’s performance at the patient level, visualize year-to-date progress toward program goals, and focus on the measures that need the most improvement.

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