Quality Payment Program Details

MIPS Highlights

  • Raising the performance threshold to 15 points in Year 2 (from 3 points in the transition year).
  • Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2, and giving you a bonus for using only 2015 CEHRT.
  • Giving up to 5 bonus points on your final score for treatment of complex patients.
  • Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters.
  • Adding 5 bonus points to the final scores of small practices

Low‐volume threshold

Excluded if, you or your group has ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries.

2018 MIPS performance year final score:

Performance category weight:

  • Quality 50%
  • Cost 10%
  • Improvement Activities 15%
  • Advancing Care Information 25%.

Performance threshold/Payment adjustment

  • The performance threshold has been set at 15 points.
  • Additional performance threshold stays at 70 points for exceptional performance.
  • Payment adjustment for the 2020 payment year ranges from ‐ 5% to + (5% x scaling factor not to exceed 3) as required by law. (The scaling factor is determined in a way so that budget neutrality is achieved).
  • Additional payment adjustment calculation is the same as in 2017.
  • The payment adjustment will be applied to the amount Medicare pays.

Performance period

  • Minimum 90‐day performance period for Advancing Care Information and Improvement Activities.
  • Minimum 12‐month performance period for Quality and Cost.
  • Exception: measures through CMS Web Interface, CAHPS, and the readmission measure are for 12 months.

Complex patients bonus

Clinicians can earn up to 5 bonus points for the treatment of complex patients (based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dually eligible patients treated).

Small practice bonus

Added 5 points to any MIPS eligible clinician or small group who’s in a small practice (defined as 15 or fewer eligible clinicians), as long as the MIPS eligible clinician or group submits data on at least 1 performance category in an applicable performance period.


  • Based on authority from the 21st Century Cures Act, we’ll reweight the Advancing Care Information performance category to 0% of the final score and reallocate the performance category weight of 25% to the Quality performance category for:
    • A significant hardship exception—We won’t apply a 5‐year limit to this exception
    • A new significant hardship exception for MIPS eligible clinicians in small practices (15 or fewer clinicians)
    • An exception for hospital‐based MIPS eligible clinicians
    • A new exception for Ambulatory Surgical Center (ASC)‐based MIPS eligible clinicians, finalized to apply beginning with the transition year and
    • A new exception for MIPS eligible clinicians whose EHR was decertified.
  • New deadline of December 31 of the performance period for the submission of reweighting applications, beginning with the 2017 performance period.
  • The definition of hospital‐based MIPS eligible clinician was revised to include covered professional services furnished by MIPS eligible clinicians in an off‐campus‐outpatient hospital (POS 19).

Ways to submit

Only 1 submission mechanism per performance category allowed.

Non‐patient facing

  • Individual ‐ If you have ≤100 patient facing encounters.
  • Groups ‐ If your group has >75% NPIs billing under your group’s TIN during a performance period considered as non‐patient facing.
  • Virtual Groups have same definition as groups. Virtual Groups that have >75% NPIs billing under the Virtual Group’s TINs during a performance period who are non‐patient facing.

Virtual Groups

  • Added Virtual Groups as a way to participate for year 2. Virtual Groups can be made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter what specialty or location) to participate in MIPS for a performance period of a year.
  • Solo practitioners and small groups may only participate in a Virtual Group if you exceed the low‐volume threshold.
  • The MIPS payment adjustments will only apply to the MIPS eligible clinicians in a Virtual Group.
  • If the group chooses to join or form a Virtual Group, all eligible clinicians under the TIN would have their performance assessed as part of the Virtual Group.
  • Components are finalized for a formal written agreement between each member of the Virtual Group.
  • Election process for 2018 runs from October 11 – December 31, 2017.
  • If certain members of a Virtual Group are in a MIPS APM, we’ll apply the APM Special Scoring Standard instead of the Virtual Group score.
  • Generally, policies that apply to groups would apply to Virtual Groups. Differences include:
    • Definition of non‐patient facing MIPS eligible clinician.
    • Small practice status.
    • Rural area and Health Professional Shortage Area designations.

Facility‐based measurement

Not available in year 2. Due to operational constraints, the facility‐based measurement proposal was delayed until year 3 of the Quality Payment Program.

Options for Small Practices (groups of 15 or fewer clinicians)

  • Excluding individual MIPS eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries.
  • Adding 5 bonus points to the final scores of small practices.
  • Giving solo practitioners and small practices the choice to form or join a Virtual Group to participate with other practices.
  • Continuing to award small practices 3 points for measures in the Quality performance category that don’t meet data completeness requirements.
  • Adding a new hardship exception for the Advancing Care Information performance category for small practices.

Gradual Implementation

The policies below were finalized to ensure that clinicians are ready for full implementation in year 3.

  • Weighting the MIPS Cost performance category to 10% of your total MIPS final score. We’re including the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures to calculate your Cost performance category score for the 2018 MIPS performance period. These two measures carried over from the Value Modifier program and are currently being used to provide feedback for the MIPS transition year. CMS will calculate cost measure performance no action is required from clinicians.
  • Increasing the performance threshold to 15 points in Year 2 (from 3 points in the transition year).
  • Continuing a phased approach to public reporting Quality Payment Program performance information on Physician Compare.

Extreme and Uncontrollable Circumstances

For 2017 Reporting Year:

  • Clinicians in affected areas that do not submit data will not have a negative adjustment. We know that the circumstances have created a significant hardship that has affected the availability and applicability of measures.
  • Clinicians that do submit data will be scored on their submitted data. This allows them to be rewarded for their performance in MIPS. Because MIPS is a composite, clinicians have to submit data on two or more performance categories to get a positive payment adjustment.
  • The policy applies to individuals (not group submissions), but all individuals in the affected area will be protect for the 2017 MIPS performance period.
  • We note that if a MIPS eligible clinician who is eligible for reweighting due to extreme and uncontrollable circumstances, but still chooses to report (as an individual or group), that they will be scored on that performance category based on their results.
  • This policy does not apply to APMs.

Virtual Groups

A Virtual Group is a combination of 2 or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter specialty or location) to participate in MIPS for a performance period of a year. CMS has developed a Virtual Groups Toolkit regarding this option.

Reporting Categories


60% in 2019 payment year.

Data completeness

  • 60% for submission mechanisms except for Web Interface and CAHPS.
  • Measures that don’t meet the data completeness criteria will earn 1 point, except for a measure submitted by a small practice, which will earn 3 points.


  • 3‐point floor for measures scored against a benchmark.
  • 3 points for measures that don’t have a benchmark or don’t meet case minimum requirements.
  • Bonus for additional high priority measures up to 10% of denominator for performance category.
  • Bonus for end‐to‐end electronic reporting up to 10% of denominator for performance category.

Topped Out Quality Measures

  • Topped‐out measures will be removed and scored on 4 year phasing out timeline.
  • Topped-out measures with measure benchmarks that have been topped out for at least 2 consecutive years will earn up to 7 points.
  • The 7‐point scoring policy for 6 topped out measures identified for the 2018 performance period is finalized. These 6 topped out measures include the following:
    • Perioperative Care: Selection of Prophylactic Antibiotic‐First or Second Generation Cephalosporin. (Quality Measure ID: 21)
    • Melanoma: Overutilization of Imaging Studies in Melanoma. (Quality Measure ID: 224)
    • Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients). (Quality Measure ID: 23)
    • Image Confirmation of Successful Excision of Image‐Localized Breast Lesion. (Quality Measure ID: 262)
    • Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description (Quality Measure ID: 359)
    • Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy. (Quality Measure ID: 52)
  • Topped-out policies do not apply to CMS Web Interface measures, and we will monitor for differences with other submission options.
  • CAHPS will be addressed in future rulemaking.


Weight to final score

Finalized at 10% in 2020 payment year.


  • Includes the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures for the Cost performance category for the 2018 MIPS performance period.
  • For the 2018 MIPS performance period, we won’t use the 10 episode‐based measures adopted for the 2017 MIPS performance period.
  • We are developing new episode‐based measures with stakeholder input and soliciting feedback on some of these measures Fall 2018.
  • We expect to propose new cost measures in future rulemaking and solicit feedback on episode‐based measures before they are included in MIPS.


  • We’ll calculate individual MIPS eligible clinician’s and group’s Cost performance using administrative claims data if they meet the case minimum of attributed patients for a measure and if a benchmark has been calculated for a measure.
  • Individual MIPS eligible clinicians and groups don’t have to submit any other information for the Cost performance category.
  • We compare your performance with the performance of other MIPS eligible clinicians and groups during the performance period so measure benchmarks aren’t based on a previous year.
  • Performance category score is the average of the 2 measures.
  • If only 1 measure can be scored, that score will be the performance category score.

Improvement scoring for Quality & Cost

For Quality

  • We’ll measure improvement at the performance category level.
  • Up to 10 percentage points available in the Quality performance category.

For Cost

  • We’ll base improvement scoring on statistically significant changes at the measure level.
  • Up to 1 percentage point available in the Cost performance category.

For Quality and Cost

  • If the improvement score can’t be calculated because there is not sufficient data, we’ll assign an improvement score of 0 percentage points.
  • CMS will figure an improvement score only when there’s sufficient data to measure improvement (e.g., MIPS eligible clinician uses the same identifier in 2 consecutive performance periods and is scored on the same cost measure(s) for 2 consecutive performance periods).

Improvement Activities

Weight to final score

15% and we measure it based on a selection of different medium and high‐weighted activities.

Number of activities

  • Finalized more activities and changes to existing activities; for a total of approximately 112 activities in the inventory.
  • Small practices; practices in rural areas, geographic health professional shortage areas (HPSAs); and non‐patient facing MIPS eligible clinicians don’t need more than 2 activities (2 medium or 1 high‐weighted activity) to earn the full score.
  • All other MIPS eligible clinicians don’t need more than 4 activities (4 medium or 2 high‐weighted activities, or a combination).

Definition of certified patient‐centered medical home

  • We’ve finalized the term “recognized” to mean the same as “certified” as a patient‐centered medical home or comparable specialty practice.
  • We’ve finalized a 50% threshold for 2018 for the number of practice sites within a TIN that need to be patient‐centered medical homes for that TIN to get full credit for the Improvement Activities performance category.


  • All APMs get at least 1/2 of the highest score, but we’ll give MIPS APMs an additional score, which may be higher than one half of the highest potential score based on their model. All other APMs must choose other activities to get additional points for the highest score.
  • Some activities qualify for Advancing Care Information bonus.
  • For group participation, only 1 MIPS eligible clinician in a TIN has to perform the Improvement Activity for the TIN to get credit.

Advancing Care Information

Weight to final score

25%, made up of a base score, performance score, and bonus points for data submission on certain measures and activities.

CEHRT requirements

  • Can use either 2014 or 2015 Edition CEHRT for the 2017 transition year.
  • A 10% bonus is available if you only use the 2015 Edition CEHRT.


  • Award a base score of 50% if you submit the numerator (of at least “1”) and denominator, or “yes” for the yes/no measure, for each required measure. If the base score isn’t met, you’ll get a 0 for the Advancing Care Information category.
  • For the performance score, you or your group may earn 10% in the performance score for reporting to any single public health agency or clinical data registry.
  • A 5% bonus score is available for submitting to an additional public health agency or clinical data registry not reported under the performance score.
  • Additional Improvement Activities are eligible for a 10% Advancing Care Information bonus if you use CEHRT to complete at least 1 of the specified Improvement Activities.
  • A 10% bonus score for using 2015 Edition exclusively.