• Physician
• Physician assistant
• Nurse practitioner
• Clinical Nurse specialist
• Certified registered nurse anesthetist
• A group that includes such professionals (required by statute)

Eligible clinician types remain the same as Year 2 with the following additions:

• Physical therapist
• Occupational therapist
• Clinical social worker
• Clinical psychologist

• First 12-month segment: Sept. 1, 2016 to Aug. 31, 2017 (including a 30-day claims run out)
• Second 12-month segment: Sept. 1, 2017 to Aug. 31, 2018 (including a 30-day claims run out)
• Note: If a clinician or group is identified as not exceeding the LVT during this time, they will be excluded regardless of the results of the second 12-month analysis

• MIPS eligible clinician furnishing 75% or more of covered professional services in POS 19, POS 21, POS 22, or POS 23 based on claims for a period prior to the performance period
• Claims will be used from September 1 of the calendar year, 2 years preceding the performance period through August 31 of the calendar year preceding the performance period; if not feasible, claims from a 12-month period close to this period will be used

• MIPS eligible clinician furnishing 75% or more of covered professional services in POS 24 based on claims for a period prior to the performance period
• Claims will be used from September 1 of the calendar year 2 years preceding the performance period through August 31 of the calendar year preceding the performance period; if not feasible, claims from a 12-month period close to this period will be used

• Created a streamlined and consistent “MIPS determination period” for different categories of clinicians, which will be used to determine the low-volume threshold and the following special statuses: non-patient facing, small practice, hospital-based, and ASC-based
• First 12-month segment: Oct. 1, 2017 to Sept. 30, 2018 (including a 30-day claims run out)
• Second 12-month segment: Oct. 1, 2018 to Sept. 30, 2019 (does not include a 30-day claims run out)
• Hospital-based MIPS eligible clinician determinations would be based on claims from the MIPS determination period
• ASC-based MIPS eligible clinician determinations would be based on claims from the MIPS determination period

• A virtual group will be considered a small practice if it contains 15 or fewer clinicians
• A virtual group will be designated as rural or HPSA practice if more that 75% of the NPIs billing under the virtual group’s TINs are designated in a ZIP code as a rural area or HPSA
• A virtual group will be considered non-patient facing if more than 75% of the NPIs billing under the virtual group’s TINs meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period

• Must be made by December 31 of the calendar year preceding the applicable performance period, and cannot be changed during the performance period
• The election process can be broken into two stages: Stage 1 (which is optional) pertains to virtual group eligibility determinations, and stage 2 pertains to virtual group formation

To meet the eligibility requirements, each member of a virtual group must establish a formal written agreement prior to an election

• A designated virtual group representative must e-mail a virtual group election to MIPS_VirtualGroups@cms.hh s.gov by December 31 of the calendar year prior to the start of the applicable performance period

• Beginning with 2019 the virtual group eligibility determination period aligns with the first segment of data analysis under the MIPS eligibility determination period.
• For example: Oct. 1, 2017 to Sept. 30, 2018 (including a 30-day claims run out)

• As part of the virtual group eligibility determination period, TINs would be able to inquire about their TIN size prior to making an election during a 5- month timeframe, which would begin on August 1 and end on December 31 of a calendar year prior to the applicable performance period. TIN size inquiries would be made through the Quality Payment Program Service Center. Technical assistance resources already available to stakeholders would continue to be available

The requirement for virtual groups to have a formal written agreement between each member of a virtual group remains the same for Year 3

• For 2019, a designated virtual group representative must e-mail a virtual group election to MIPS_VirtualGroups@cms.hhs.g ov by December 31 of the calendar year prior to the start of the applicable performance period

• Quality: 12-months
• Cost: 12-months
• Improvement Activities: 90-days
• Promoting Interoperability: 90-days

• Same performance periods as in Year 2

• 50% in Year 2
• The Quality performance category may be reweighted
• If a score cannot be calculated due to no applicable and available measures
• Due to extreme and uncontrollable circumstances

For individual eligible clinicians, one submission mechanism must be selected:

• Claims
• QCDR
• Qualified registry
• EHR

• QCDR
• Qualified registry
• EHR
• CMS Web Interface (groups of 25+)
• CMS-Approved Survey Vendor for CAHPS for MIPS

• Claims: 60% of Medicare Part B patients for the performance period
• QCDR/Registry/EHR: 60% of clinician’s or group’s patients across all payers for the performance period
• CMS Web Interface: Sampling requirements for Medicare Part B patients
• CAHPS for MIPS Survey: Sampling requirements for Medicare part B patients

Definition: if measure performance is so high and unvarying that meaningful distinctions and improvement in performance can no longer be made. QCDR measures would not go through the comment and rulemaking process to remove topped out measures. Policies include:

• Finalized 4-year lifecycle for identification and removal of topped out measures
• Scoring cap of 7 points for topped out measures
• Policies to identify, remove and cap scoring for topped out measures do not apply to CMS Web Interface measures
• Policy does not apply to CAHPS for MIPS Summary Survey Measures (SSMs)
• 6 measures identified for scoring cap for topped out measures

• No requirements

• 2 points for outcome, patient experience
• 1 point for other high priority measures which need to meet data completeness, case minimum, and have performance greater than 0
• Capped bonus points at 10% of the denominator of total Quality performance category

• 1 point for each measure submitted using electronic end-to-end
• Capped at 10% of the denominator of total Quality performance category points

• Eligible clinicians must fully participate (i.e., submit all required measures and have met data completeness criteria, and for performance year
• The quality improvement percent score is 0 if the eligible clinician did not fully participate in the quality category for the current performance period
• If the eligible clinician has a previous year Quality performance category score less than or equal to 30%, we would compare 2018 performance to an assumed 2017 Quality category score of 30%

• 45% in Year 3
• Maintain the same reweighting criteria for the Quality Performance category

In Year 3, individual eligible clinicians would be able to submit a single measure via multiple collection types (e.g. MIPS CQM, eCQM, QCDR measures and Medicare Part B claims measures) and be scored on the data submission with the greatest number of measure achievement points

• The Quality performance category would be scored if groups submit data using multiple collection types (e.g. MIPS CQM, eCQM, QCDR measures, and Medicare Part B claims measures)
• CMS Web Interface cannot be scored with other collection types other than the CMS approved survey vendor measure and/or administrative claims measures

• The same data completeness requirements as Year 2, with the following change:
• For groups registered to report the CAHPS for MIPS survey, there is an additional policy. If the sample size was not sufficient, the total available measure achievement points (the denominator) would be reduced by 10 points and the measure would receive zero points

• The definition and lifecycle for topped out measures remain the same for Year 3, although additional factors may affect the time a topped-out measure remains as such

• In response to clinical guideline or other changes, impacted measures will be given a score of 0 and the Quality performance category denominator would be reduced by 10. If this situation occurs the clinician would be required to submit data for one less measure (i.e. 5 measures instead of 6)

• Same as Year 2, with the following change:
• Discontinue high priority measure bonus points for CMS Web Interface Reporters

• Same as Year 2.

• Same as Year 2

• 10% in Year 2

• Two measures: Total Per Capita Cost and Medicare Spending Per Beneficiary (MSPB)
• Derived from Medicare claims
• Reliability threshold of 0.4
• Case minimum of 20 for total per capita cost and 35 for MSPB

• Plurality of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
• Plurality of Part B services billed during the index admission to determine attribution for the MSPB measure
• Added two CPT codes (99487 and 99489 describing complex chronic care management) to list of primary care services used to determine attribution under the total per capita cost measure

• Improvement scoring added to the Cost performance category scoring methodology with a maximum cost improvement score of 1 percent;
• However, the Bipartisan Budget Act of 2018 delayed consideration of improvement in the Cost performance category until the 2024 payment year (based on the 2022 performance year). As a result, there will be no improvement scoring in Year 2 MIPS payment year.

• Cost Achievement Points/Available = Cost Performance Category Percent Score
• The percent score cannot not exceed 100%
• The Bipartisan Budget Act of 2018 delayed consideration of improvement in cost until the 2024 MIPS payment year (based on the 2022 performance year)
• We will not calculate a Cost performance category score if the eligible clinician is not attributed any Cost measures, because of case minimum requirements or the lack of a benchmark

• 15% in Year 3

The Total Per Capita Cost and MSPB measures will be the same as in Year 2, with the following changes:

• 8 episode-based measures will be added to the list of Cost measures
• Case minimum of 10 for procedural episodes and 20 for acute inpatient medical condition episodes

Same as Year 2 with the following changes:

• For procedural episodes, we will attribute episodes to each MIPS eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes
• For acute inpatient medical condition episodes, we will attribute episodes to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30 percent of the inpatient E&M claim lines in that hospitalization

• Cost performance category percent score will not take into account improvement until the 2024 MIPS payment year

• Same as Year 2

• Not Applicable

• Not Applicable

• Not Applicable

• Not Applicable

• Not Applicable

• Not Applicable

• Not Applicable

• Not Applicable

• Not Applicable

• For facility-based scoring, the measure set for the fiscal year Hospital Value-Based Purchasing (VBP) program that begins during the applicable MIPS performance period will be used for facility-based clinicians

• MIPS eligible clinician furnishes 75 percent or more of their covered professional services in inpatient hospital, on-campus outpatient hospital, as identified by POS code 22, or an emergency room, based on claims for a period prior to the performance period
• Clinician must have at least a single service billed with the POS code used for the inpatient hospital or emergency room

• Facility-based group is one in which 75 percent or more of the MIPS eligible clinician NPIs billing under the group’s TIN are eligible for facility-based measurement as individuals

• A facility-based clinician is attributed to the hospital at which they provide services to the most Medicare patients
• A facility-based group is attributed to the hospital at which a plurality of its facility-based clinicians are attributed
• If unable to identify a facility with a VBP score to attribute a clinician’s performance, that clinician is not eligible for facility-based measurement and will have to participate in MIPS via other methods

• Automatically apply facility-based measurement to MIPS eligible clinicians and groups who are eligible for facility-based measurement and who would benefit by having a higher combined Quality and Cost score
• No submission requirements for individual clinicians in facility-based measurement but a group must submit data in the Improvement Activities or Promoting Interoperability performance categories in order to be measured as a group under facility-based measurement

• Benchmarks for facility-based measurement are those that are adopted under the Hospital VBP program of the facility for the year specified

• Both the Quality performance category score and Cost performance category score for facility-based measurement are reached by determining the percentile performance of the facility determined in the VBP program for the specified year and awarding a score associated with that same percentile performance in the MIPS Quality and Cost performance category scores for those clinicians who are not scored using facility-based measurement

• Given that improvement is already captured in the distribution of the MIPS performance scores that is used to translate a Hospital VBP Program Total Performance Score into a MIPS Quality performance category score, there is no additional improvement scoring for facility-based measurement for either the Quality or Cost performance category

• Some hospitals do not receive a Total Performance Score in a given year in the Hospital VBP Program, whether due to insufficient quality measure data, failure to meet requirements under the Hospital IQR Program, or other reasons. In these cases, we would be unable to calculate a facility-based score based on the hospital’s performance, and facility-based clinicians would be required to participate in MIPS via another method

• 15% in Year 2

• Initial inventory established based on research, environmental scan and priorities
• In Year 2, the Annual Call for submitting Improvement Activities, was established

• Submissions at any time during the performance period to create an Improvement Activities Under Review (IAUR) list; submissions received by March 1st will be considered for inclusion in the following calendar year

• Study purpose, participation credit and requirements and study procedures updated from Year 1 establishment

• Certain improvement activities will qualify for a bonus under the PI performance category

• 15% in Year 3

• In Year 3, the timeframe for the Annual Call for Activities and the improvement activities inventory would be modified
• Modifications include the addition of one new criteria in this category, “Include a public health emergency as determined by the Secretary,” and the removal of, “Activities that may be considered for a Promoting Interoperability bonus”
• Adding 6 new Improvement Activities
• Modification of 5 existing Improvement Activities
• Removal of 1 existing Improvement Activity

• Improvement activity nominations received in Year 3 will be reviewed and considered for possible implementation in Year 5 of the program
• The submission timeframe/due dates for nominations would be from February 1st through June 30th, providing approximately 4 additional months to submit nominations

• The CMS study title would be changed to, “CMS Study on Factors Associated with Reporting Quality Measures”
• The sample size would be increased to 200 MIPS eligible clinicians with focus group requirements for only a subset of study participants
• We are also proposing to limit the focus group requirement to a subset of the 200 participants, and require that at least one of the minimum of three required measures be either an outcome or a high priority measure

• In Year 3, the Promoting Interoperability bonus will be removed

• 25% in Year 2

• Reasons to reweight the PI category to 0% include:
• Nurse practitioner, physician assistant, clinical nurse specialist, or certified registered nurse anesthetist
• Significant hardship (e.g. lack of internet, extreme and uncontrollable circumstances, small practice)
• 50% or more of patient encounters occurred in practice locations where no control over the availability of CEHRT
• Non-patient facing
• Hospital-based
• ASC-based
• Automatic reweighting for extreme and uncontrollable circumstances
• Even if the category could be reweighted
• MIPS eligible clinicians using decertified EHR Technology, exception available for no more than 5 years
• For any of the above reasons, if a MIPS eligible clinician reports PI (formerly ACI) measures and objectives, they will be scored like other MIPS eligible clinicians and the PI performance category will not be reweighted to 0%

• Eligible clinicians may use either the 2014 or 2015 Edition CEHRT or a combination of the two; one-time bonus of 10 percentage points in if using only 2015 Edition CEHRT

• Performance category score is comprised of the base, performance, and bonus score
• Clinicians must complete the base score requirements in order to receive a score in the category

• Two measure set options for reporting based on the clinician’s CEHRT edition (either 2014 or 2015).

• 25% in Year 3

• Reweighting of the Promoting Interoperability performance category remains the same as Year 2 and extends to additional clinician types (physical therapists, occupational therapists, clinical social workers, and clinical psychologists)

• Eligible clinicians must use 2015 Edition CEHRT in Year 3

• Eliminating base, performance, and bonus scores
• Proposing a new scoring methodology
• Performance-based scoring at the individual measure-level. Each measure would be scored based on the MIPS eligible clinician’s performance for that measure based on the submission of a numerator or denominator, or a “yes or no” submission, where applicable
• The scores for each of the individual measures would be added together to calculate the score of up to 100 possible points. If exclusions are claimed the points for measures will be reallocated to other measures

• One objectives and measure set based on the 2015 Edition CEHRT
• Four objectives: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange
• Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed
• Proposing to add two new measures to the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement

• Quality: 50%
• Cost: 10%
• PI: 25%
• IA: 15%

If a MIPS eligible clinician is scored on fewer than two performance categories, a final score equal to the performance threshold will be assigned and the MIPS eligible clinician will receive an adjustment of 0%

• A bonus of 5 points is added to the final score for MIPS eligible clinicians, groups, virtual groups and APM Entities that meet the definition of small practice and submit data on at least one performance category in the 2018 performance period

• Quality: 45%
• Cost: 15%
• PI: 25%
• IA: 15%

If a MIPS eligible clinician is scored on fewer than two performance categories, a final score equal to the performance threshold will be assigned and the MIPS eligible clinician will receive a payment adjustment of 0%

• The small practice bonus will now be added to the Quality performance category, rather than in the MIPS final score calculation
• Add 3 points in the numerator of the Quality performance category for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure

• Finalized that for each MIPS payment year, the MIPS payment adjustment factor, and if applicable, the additional MIPS payment adjustment factor, are applied to Medicare Part B payments for items and services furnished by the MIPS eligible clinician during the year
• However, the Balanced Budget Act of 2018 changed this so that the MIPS adjustment factors will apply to ‘covered professional services’ under the physician fee schedule beginning with the 2019 payment year
• Finalized application of the payment adjustment to the Medicare paid amount

• For individual eligible clinicians, we will use the final score associated with the TIN/NPI used during the performance period
• For groups submitting data using the TIN identifier, we will apply the group final score to all the TIN/NPI combinations that bill under the TIN during the performance period
• For eligible clinicians in a MIPS APM, we will assign the APM Entity group’s final score to all APM Entity Participant National Provider Identifiers associated with the APM Entity
• For eligible clinicians that participate in APMs for which the APM scoring standard does not apply, we will determine a final score using either the individual or group data submissions
• If a MIPS eligible clinician is not in an APM Entity and is in a virtual group, the MIPS eligible clinician would receive the virtual group final score over any other final score

• Same as Year 2

• Remains the same as Year 2, with one change. MIPS eligible clinicians in a group practice who qualify for a group final score will have a modified determination period to include:
• 15-month window that starts with the second 12-month determination period (October 1 prior to the MIPS performance period through September of the current MIPS performance period)
• Proposed policy to assign a weight of 0% to each of the four performance categories and a final score equal to the performance threshold when:
• MIPS eligible clinician joins an existing practice (TIN) in the final three months of the performance period year and the practice is not participating in MIPS as a group
• MIPS eligible clinician joins a practice that is a newly formed TIN in the final three months of the performance period year

• Performance Threshold is set at 15 points
• Additional performance threshold set at 70 points for exceptional performance
• MIPS eligible clinicians receive a payment adjustment and, if applicable, an additional payment adjustment, determined by comparing final score to performance threshold and additional performance threshold
• A final score at or above the performance threshold receive a zero or positive payment adjustment and a score below the performance threshold receive a negative adjustment
• As required by statute, the maximum negative payment adjustment is -5 percent positive payment adjustments can be up to 5% (but they are multiplied by a scaling factor to achieve budget neutrality)
• The additional payment adjustments for exceptional performance starts at 0.5% and goes up to 10% x scaling factor not to exceed 1

• Performance Threshold is set at 30 points
• Additional performance threshold set at 80 points for exceptional performance
• As required by statute, the maximum negative payment adjustment is -7 percent. Positive payment adjustments can be up to 7% (but they are multiplied by a scaling factor to achieve budget neutrality)
• The additional payment adjustment for exceptional performance shall be applied in the same way as in 2018 for scores at or above the additional performance threshold