For the Merit-based Incentive Payment System (MIPS), CMS reviews past and current Medicare Part B Claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each Performance Year (each review is called a determination segment). Data from the two segments is then reconciled and released as the final eligibility determination. (https://qpp.cms.gov/mips/how-eligibility-is-determined)
Reporting Thresholds
Clinicians and practices must exceed the low-volume threshold during both review periods to be eligible for MIPS.
You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments of the MIPS Determination Period, you:
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Bill more than $90,000 for Part B covered professional services, and
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See more than 200 Part B patients, and;
- Provide more than 200 covered professional services to Part B patients.
Participation Status
There are different ways to become a MIPS eligible clinician, depending on whether you’re reporting as an individual or part of a group.
NOTE: If CMS determines a given eligible provider (EP) is "Individual Exempt" and the EP elects to reports as an Individual, then no Payment Adjustment will be assigned, regardless of data submitted. It is much more common for EPs to report as a Group because their group volume exceeds the low-volume threshold making them eligible to receive a positive Payment Adjustment.
Find any EP's Participation Status at: https://qpp.cms.gov/participation-lookup
Reporting Options
Each TIN may report as either a "Group", "Individual", or "Both". Recall "MACRA Exempt" status is evaluated for each NPI on both an individual and group basis. That is, the "MACRA Exempt" criteria are applied at the NPI level (i.e. all cases for an NPI) and to the TIN level (i.e. all cases for a TIN). If a given NPI is deemed "Individual MACRA Exempt" by CMS and the elect to report as an Individual, then they will not receive a penalty or a bonus. Rather, CMS will label them as a "Voluntary Submitter" and while they still will receive a CPS, it will provide no financial adjustment - negative or positive.
Report as an Individual
If reporting only as an individual, the NPI's measures and activities for the given TIN will be reported to the QCDR. Composite Performance Scores will be based on individual EP's performance.
Report as a Group
If reporting as a group, all NPIs' measures and activities for the given TIN will be reported to the QCDR. The group’s performance data across the 4 Performance Categories for a single TIN will be evaluated in aggregate. Each EP in the TIN group will then receive the same CPS based on the group's performance.
If reporting as a Group, it is important to ensure you report quality data for ALL NPIs within a given TIN. For a complete list of all NPIs within your TIN please check your CMS portal at https://portal.cms.gov