Skip to content
1-866-359-4458 Log In
Get Started

MIPS Eligibility: Who must participate and who is exempt from MIPS participation and reporting?

There are no major changes to MIPS eligibility for the 2020 performance year. As always, a key question clinicians and practices should be asking themselves when preparing to participate in MIPS is: “Am I considered an ‘Eligible Clinician’? And if so, do I meet any of the exemption criteria that would allow me to avoid the penalty without participating?”

Let’s dive into the factors impacting participation requirements:

  • Clinician type
  • Volume of care to Medicare patients
  • CMS determination period
  • Special statuses and APM participation

MIPS eligibility is based on a clinician’s National Provider Identifier (NPI) and the associated Taxpayer Identification Numbers (TINs), referred to as the TIN/NPI combination.

For 2020, MIPS Eligible Clinicians include:

  • Physicians
  • Certified Registered Nurse Anesthetist (CRNA)
  • Clinical Nurse Specialist (CNS)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Clinical Psychologist
  • Physical Therapist
  • Occupational Therapist
  • Speech-Language Pathologist
  • Audiologist
  • Registered Dietician or Nutrition Professional

Clinicians newly enrolled in Medicare for the first time on or after January 1st of the current performance year are exempt from participation. Certified nurse-midwives and clinical social workers are still excluded at this time.

Volume Threshold

MIPS eligible clinicians do not have to participate in the program if they are otherwise eligible but do not meet the volume threshold for allowable charges, Medicare patients, and billable services. CMS calculates eligibility using two standard MIPS Determination Periods which we’ll explain this in a moment.

Here’s how the volume threshold exclusion works; providers are excluded if:

  • Have <= $90,000 in allowable charges
  • Or, <= 200 Medicare patients
  • Or, <= 200 Charge Line Items

If providers or groups meet one of the criteria, they may opt-in to participate in MIPS by making an irrevocable election in the QPP portal.

Included Excluded May Opt-In
> $90k Allowable Charges ≤ $90k Allowable Charges > $90k Allowable Charges
AND, > 200 Medicare Patients OR, ≤ 200 Medicare Patients OR, > 200 Medicare Patients
AND, > 200 Charge Line Items OR, ≤ 200 Charge Line Items OR, > 200 Charge Line Items

MIPS Determination Period

CMS calculates MIPS eligibility within two determination periods for a performance year – here’s the 2020 example:

  • 1st Determination Year: October 1, 2018 to September 30, 2019 (includes 30-day claims run out)
  • 2nd Determination Year: October 1, 2019 to September 30, 2020 (does not include 30-day claims run out)

For each determination period, CMS calculates for clinicians and practices the low-volume threshold and any special statuses which may reduce reporting requirements. Qualifying APM Participant (QP) statuses are calculated during the performance year with the final determination being in December of the current year.

The eligibility determination information for each TIN/NPI combination is made available in the QPP Participant Lookup Tool here.

Special Statuses, MIPS Exemptions (including COVID-19), and Qualifying APM Participants

Even if clinicians fall into the Eligible Clinician category, that does not necessarily mean the clinician or practice will receive a penalty for not participating in MIPS.

There are several special statuses and exemptions for one or all component(s) of the MIPS program including:

  1. Providers newly enrolled in Medicare for the first time during the performance period
  2. Providers participating in an Advanced Alternative Payment Model (APM) as a “Qualifying APM Participant” (QP)
  3. Providers who fall below the low-volume threshold
  4. MIPS Promoting Interoperability Hardship Exemption[BG1]
  5. Extreme and uncontrollable circumstances Exemption (esp. COVID-19)
  6. Special statuses that change reporting requirements: small practices, non-patient facing, hospital-based, ASC-based
Special Statuses

Under MIPS, CMS automatically assigns special statuses to clinicians, practices, and virtual groups who meet certain criteria. Reporting requirements may change if a special status is received.

The statuses can be complicated. Your Mingle Consultant can help you navigate the requirements and how they are impacted by different statuses.

Status Automatic Reweighting of PI category to 0% 2x the points for each Improvement Activity submitted
Ambulatory Surgery Center (ASC)-based
Hospital-based
Non-patient facing
Small practice
Health Professional Shortage Area (HPSA)
Rural
Facility-based Hospital Value-Based Purchasing (VBP) Program score used for Quality and Cost performance categories; Quality data can be submitted, and highest score will apply

For example, let’s consider an example where the “Small Practice” status may apply. If applicable, you will earn 2x the points for each improvement activity you submit. If you submit at least one quality measure, you will also receive 6 bonus points in the Quality performance category. Here’s the criteria:

Level You will Receive “Small Practice” Special Status if …
Clinician The MIPS eligible clinician is one of 15 or fewer clinicians billing under the practice’s TIN
Practice 15 or fewer clinicians bill under the practice’s TIN
Virtual Group 15 or fewer clinicians bill under TINs that participate in virtual group

Courtesy CMS 8/3/2020 (qpp.cms.gov/mips/special-statuses)

Facility-Based Determination

If a clinician is identified as being facility-based, and the facility has a Hospital Value-Based Purchasing (VBP) Program score, the practice will not need to submit MIPS Quality performance category data. The Hospital VBP score can be used for Quality and Cost categories if the practice submit a group submission for the MIPS Improvement Activities (IA) and/or Promoting Interoperability categories. A practice may still submit Quality data under MIPS and CMS will use the data resulting in the highest MIPS score.

QPP Exemptions and Application

CMS has provided an exemption for those who experience circumstances out of their control that make it difficult to meet program requirements. For 2020, there are two exemption applications:

  1. Extreme and Uncontrollable Circumstances Exemption: request reweighting for any or all performance categories if you encounter an uncontrollable circumstance or public health emergency, such as COVID-19, that is outside your control
  2. MIPS Promoting Interoperability Hardship Exemption: request reweighting of the PI category if you meet the qualifying criteria.

Unless CMS has announced you’re in an area where an exemption was automatically applied based on a FEMA designated disaster area (such as a high-impact hurricane area), you must submit an application by December 31 for an exemption.

For all applications, you must provide justification for why you qualify for an exemption. Talk to a member of the Mingle team for assistance in understanding your options.

If you submit data for two or more MIPS performance categories, you will be scored on that submission regardless of having received an exemption. You can also choose to report even if you were approved for an exception.

Reminder: 2015 CHERT is required for MIPS; lacking CHERT does not qualify you for reweighting unless you meet the criteria for an exception and are approved.

APM Participation

The Quality Payment Program encourages participation in Advanced Alternative Payment Models (APMs). Depending on the type of APM, clinicians may or may not need to participate in MIPS. Clinicians determined to be Qualifying APM Participants (QPs) are exempt from MIPS.

CMS QPP Participant Tool

Utilize the CMS QPP Participant Status lookup tool for the latest eligibility for your NPI/TIN combination.

Access the CMS QPP Participant Tool

Q&A from Our Readers

To help further your understanding of MIPS eligibility and exemptions, we are sharing, below, our answers to your most commonly asked questions. If you still have questions after finishing this post, please post them in the comments section below or get in touch here (or via the live chat); we are standing by to answer them for you!

Q.  What if I have questions about our participation status on the QPP site?

A.  Mingle Health is here to help you understand the requirements and your path to success. One option we’ll guide you through is submitting questions to the Quality Net Help Desk for assistance and understanding the CMS data that led to their determination.

Q.  Who is exempt from MIPS based on the “Low Volume Threshold”?

A.  A clinician is exempt from MIPS under the Low Volume Threshold if they have fewer than or equal to $90,000 annual allowed Medicare Part B charges and/or see 200 or fewer unique Medicare Part B patients, and/or offer 200 or fewer Medicare services.

Q.  Are all specialties subject to participation?

A.  Eligibility requirements for the new Quality Payment Program apply across the board to all specialties. However, there are some special scoring rules in Promoting Interoperability and Improvement Activities for hospital-based clinicians, or those who do not have a specific number of face-to-face encounters.

Q.  Our PA’s bill under the supervising doctor’s NPI. Will we have to change our billing process?

A.  You can continue to bill as you are but only the supervising physician’s data will be reported for MIPS. As long as your PA’s do not independently bill for Medicare Part B charges, they will not have to participate. Check the QPP participation tool for the most up-to-date information for each unique NPI in your practice.

Q.  Is there a penalty applied if an Eligible Clinician falls under the low-volume threshold exemption?

A.  There will be no penalty under the low-volume threshold exemption.

Q.  We have a Nurse Practitioner who enrolled in Medicare in October 2019. Are they considered newly enrolled for 2020, therefore becoming exempt from 2020 MIPS reporting?

A.  Clinicians are only considered newly enrolled in Medicare if they enrolled on or after January 1 for the current performance year.

Q.  Is the low-volume threshold exemption based on 90 days of data or a full year?

A.  The low-volume threshold is determined on a full year of data. CMS has two determination periods where this will be evaluated to see if Eligible Clinicians meet these criteria.

Q. What are the determination periods CMS will use to determine low-volume, non-patient facing, and hospital-based?

A. There are two determination periods. E.g. for 2020: The first period is October 1, 2018 – September 31, 2019. The second period is October 1, 2019 – September 31, 2020. If a provider is considered exempt in either determination period, they are exempt.

Q.  Our clinicians meet the low-volume threshold exemption, will there be any benefit from still participating in MIPS even though they will be exempt?

A. There can be benefits to participating even if a provider is exempt based on the volume threshold. If a clinician is excluded due to low-volume, but reports as an individual, they would benefit by preparing for when reporting might be required in the future. If a low-volume clinician reports as part of the group, they will benefit from the same payment adjustment that the rest of the group receives.

Q. How do we opt-in to participate?

If a clinician or practice would otherwise be MIPS eligible and exceeds at least one of the low-volume criteria, they can likely make an irrevocable election to opt-in to MIPS participation for the performance year. If a practice opts-in and reports as a group, individual clinicians do not need to opt-in to receive the group score and payment adjustment.

 Q.  We would like to report as a group. How does this affect the low-volume providers?

A.  If reporting as a group, everyone’s data is included, even if they would otherwise be exempt if reporting as individuals and they will enjoy the same adjustment that is applied to the group.

 

 

Succeed with MIPS and the Quality Payment Program

Dr. Dan Mingle shares key changes and strategies for success in 2020 for MIPS.

Watch the Webinar
Get Helpful News & Resources
  • This field is for validation purposes and should be left unchanged.