MIPS Eligibility & Exemptions



Who is considered a MIPS eligible clinician?

To check your specific eligibility, use our online MIPS reporting eligibility tool.

Performance Year

Adjustment Year

MIPS Eligible Clinicians

2017+

2019+

Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists

2019+

2021+

Physical / Occupational Therapists, Speech-Language Pathologists, Audiologists, Nurse Midwives, Clinical Psychologists, Dietitians/Nutritional Professionals

Please note that CMS defines a physician as “a doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a state in which he/she performs this function.”

Possible Exemptions for MIPS Eligible Clinicians

1

Participation in an Advanced Alternative Payment Model (APM)

If an eligible clinician is a part of an Advanced APM, then they are exempt from MIPS reporting. Current examples of APMs are Accountable Care Organizations (ACO), Patient Centered Medical Homes, and bundled payment models.

2

MACRA Quality Payment Program Low-Volume Threshold

Otherwise eligible clinicians or groups will be exempt from MIPS reporting if they bill ≤ $90,000 or provide care for ≤ 200 Medicare Part B patients.

3

Newly Enrolled in Medicare

If a clinician enrolls in Medicare in the middle of a performance year, they do not have to participate in MIPS reporting that year. For example, if a clinician was to enroll in Medicare on February 6, 2019, they would be exempt for the 2019 performance year (January 1, 2019- December 31, 2019).

How Is 2018 MIPS Eligibility and Participation Determined?

Clinicians Included in MIPS

  • Physicians (including doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Groups or virtual groups that include one or more of the clinician types above

If you’re included in MIPS for Performance Year 2018, you will need to decide whether to report as an individual or group.

Clinicians Exempt From MIPS

  • Clinicians who are not one of the clinician types above
  • Clinicians who enroll in Medicare for the first time in 2018
  • Clinicians who participate in an Advanced APM and are either a Qualifying APM Participant (QP) or Partial QP
  • Clinicians who are not in a MIPS eligible specialty
  • Clinicians or groups that have billed $90,000 or less in Physicial Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare secondary Payer)
  • Clinicians or groups that have 200 or fewer Medicare Part B FFS beneficiaries
    If you’re exempt from MIPS for Performance Year 2018, you are not required to participate. However, you are encouraged to check your participation status again if you’ve made any changes that may change your eligibility status.

Clinicians Participating in Advanced APMs

For Performance Year 2018, if you have a certain percentage of your Part B payments through an Advanced APM or see a certain percentage of your patients through an Advanced APM, you will not have to submit data to MIPS.

During the QPP Performance Year, CMS will take three “snapshots” (on March 31, June 30, and August 31) to see which Advanced APM participants meet the thresholds to become Qualifying APM Participants (QPs).

If you participate in Advanced APMs, but do not meet the threshold, you may become a Partial QP. Partial QPs can choose if they want to participate in MIPS.

Review Periods

For Performance Year 2018, your eligibility was reviewed at two different times during the Performance Year.

Review Dates

For Performance Year 2018, the first review was completed in December 2017 by examining claims from September 1, 2016 through August 31, 2017. CMS reviewed Medicare Part B Claims data and PECOS data and will only apply it to PY 2018.

CMS completed the second review in late 2018. They examined Medicare Part B Claims data from September 1, 2017 through August 31, 2018 and PECOS data. If you joined a new practice during this time period, your eligibility under that practice was evaluated during the second review. Check your final status with our online MIPS eligibility tool.


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