What is MIPS?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaced it with a new value-based reimbursement system called the Quality Payment Program (QPP).  The QPP consists of two tracks:

  • The Merit-based Incentive Payment System (MIPS)
  • Advanced Alternative Payment Models (Advanced APMs)

The focus of this FAQ is on MIPS as a majority of eligible providers will be reporting through the MIPS track.

Starting in January 2021, MIPS will measure eligible providers in four performance categories to derive a final MIPS composite score of “0 to 100”. The four categories with their individual assigned scores in 2021 are:

  • Quality = 40%
  • Promoting Interoperability (PI) = 25%
  • Improvement Activities (IA) = 15%
  • Cost = 20%

How does MIPS work?

MIPS is a composite score based payment system such that higher score results in the potential for higher incentive and vice versa. Thresholds have been set for clinicians to meet and avoid a negative adjustment, while exceeding the threshold may result in a positive adjustment.

What is the financial impact of MIPS?

Starting in 2019, CMS had allotted an additional $500 million per year through 2022 towards the exceptional bonus pool. With performance scoring only impacting those clinicians with a score greater than 85 points, the potential impact of the MIPS scoring system to clinician reimbursement will be significant. MIPS will financially impact Medicare Part B providers by a performance adjustment. This is a negative or positive adjustment soleby based on performance.


The adjustment tiers are detailed below:

Performance Year

Payment Year


Base Incentives

Exceptional Performance Score Threshold

Exceptional Performance Bonus

Maximum Incentive











































How will MIPS affect your practice or healthcare organization visibility?

The reputational impact of MIPS makes it even more important for you to understand where you stand today against existing benchmarks as well as what changes you can make to have the most impact on your performance, quality of care, and MIPS score.

Medicare Physician Compare Website currently shows whether the physician reported on the quality measures and used electronic health records. This website was completed September 2015 as part of the Physician Compare Initiative. The physician’s scores are available on this website, allowing patients to compare physician performance and help them make informed decisions about their care. Basically, your MIPS score will influence your visibility and reputation, which can impact patient retention and revenues.

Who is eligible for MIPS in 2021?

Certified Registered NurseCertified Registered Nurse
Anesthetist (CRNA)Anesthetist (CRNA)
Clinical Nurse Specialist (CNS)Clinical Nurse Specialist (CNS)
Nurse Practitioner (NP)Nurse Practitioner (NP)
Physician Assistant (PA)Physician Assistant (PA)
Clinical PsychologistClinical Psychologist
Physical TherapistPhysical Therapist
Occupational TherapistOccupational Therapist
Speech-Language PathologistSpeech-Language Pathologist
Registered Dietician or NutritionProfessionalRegistered Dietician or NutritionProfessional

What is the MIPS eligibility criteria in 2021?

To be able eligible to participate the clinician must meet the following three requirements:

1. Medical billing greater than $90,000
2. Beneficiaries greater than 200
3. Services greater than 200

Opt-in option (newly added in 2019)

  • Opt-in is available for MIPS eligible clinicians who are excluded from MIPS based on the low-volume threshold determination
  • If you are a MIPS eligible clinician and meet or exceed at least one, but not all, of the low-volume threshold criteria, you may opt-in to MIPS
  • If you opt-in, you’ll be subject to the MIPS performance requirements, MIPS payment adjustment, etc.


Note: You can voluntarily report if you are a clinician or group that is not MIPS eligible. If you report voluntarily, you will receive a MIPS final score but no payment adjustment.

Do I need to report as an Individual or as a part of a Group?

A clinician may choose to report either on an individual or a group basis. When considering reporting as a group one should consider multiple factors, including number of providers, type of providers in practice and specialty of providers. When reporting individually only MIPS eligible clinicians would be required to report under his or her TIN. While reporting as part of a group each clinician would need to be considered for reporting under the group TIN.

Which data submission methods are available for Individual Provider MIPS reporting?

The methods available for reporting each MIPS component for individual clinician are:

Promoting Interoperabilityxxxx
Improvement Activitiesxxxx

Note: Multiple reporting methods are allowed for 2021 MIPS reporting.

Which data submission methods are available for Group MIPS reporting?

Promoting Interoperabilityxxxx
Improvement Activitiesxxxx

What are the reporting requirements for each MIPS category?

CategoryWhat do you need to do?
QualityMultiple collection and reporting methods accepted
1 Hi-Priority/Outcome Measure Required

  • 2 Points Outcome, Patient Experience extra measure
  • 1 Point – Other high priority measures which need to meet the data completeness and case minimum requirements along with having a performance rate of greater than zero
  • High priority measures will include measures that relate to opioids.

Small practice bonus points apply to Quality Category (6 points)

Promoting Interoperability2015 edition CEHRT required
PDMP Bonus (10 Points)
eRX now scored
Improvement Activities
  • Removed 1 Improvement Activity, and modified 1
  • CEHRT bonus removed
  • Small practices still get double credit
CostAdded 8 episode-based measures
Some data collection changes for the TPCC measures that impact specialty physicians
No change in reporting requirements; data pulled from claims filed with Medicare