iPatientCare Blog - MIPS Participation- Part-1 - Decoding Eligibility Criteria

MIPS Participation- Part-1 – Decoding Eligibility Criteria

CMS has come up with a tool (https://qpp.cms.gov/learn/eligibility) to check your MIPS eligibility status. They are also sending out letters to clinicians informing them about the MIPS Participation Status. What is this all about?

MIPS is one of the pathways under MACRA that streamline multiple reporting programs (PQRS, Physician Value Modifier and Medicare EHR Incentive Program) into a single program called Merit based incentive payment system (MIPS). 2017 is the first performance year for MIPS and 2019 is the first payment year. Based on your performance data for 2017, you would receive payment adjustment for items and services provided under Medicare Part B in 2019. To help the Clinicians know their eligibility status, CMS is sending out letters to all practices enrolled in Medicare. This letter will tell the participation status of each MIPS clinician associated with the Taxpayer Identification Number or TIN in a practice.

MIPS Participation - Decoding Eligibility Criteria

Who is Eligible for MIPS?

For performance period 2017, Clinicians who have billed more than $30,000 in Medicare Part B allowable charges and have more than 100 Part B-enrolled Medicare beneficiaries are eligible for MIPS. These include 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’s assistants, Nurse practitioners, Clinical nurse specialists, Certified registered nurse anesthetists and groups that includes such clinicians. Clinicians in their first year of Medicare, those who bill less than $30,000 OR who provide care to less than 100 Medicare beneficiaries in a year, participants of advanced APMs and those who are not in the MIPS-eligibility specialty are exempted.

How is the Eligibility Determined?

CMS will review your eligibility two times in the year. First review is based on the historical claim data submitted between 1st September 2015 and 31st August 2015. Second review would be completed in December on the performance period claim data submitted between 1st September 2016 and 31St August 2017. Staying below the low volume threshold in either of the review period will exempt the clinician from MIPS.

For participating as an individual, the low volume threshold would be calculated separately for each NPI-TIN combination. If a clinician is associated with multiple TINs, his eligibility would be determined separately for each TIN-NPI. For participation as a group, the low volume threshold is calculated for the group as a collective entity.

Clinicians Practicing in Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs):

Clinicians practicing in RHCs and FQHCs who provide services that are billed under the RHC’s or FQHC’s payment methodologies are not required to participate in MIPS. If they provide other services and bill those under the Physician Fee Schedule (PFS), they would be required to participate and receive payment adjustments.

Clinicians Practicing in Critical Access Hospitals (CAHs):

Clinicians practicing in CAHs are required to participate unless they are exempted. Payment adjustments would apply to payments made for items and services billed to Medicare Part B by the eligible clinicians (or to the Method II CAHs payment if the clinicians are practicing in Method II CAHs and have assigned their billing rights to the CAH).

Hospital Based Clinicians:

Clinicians who provide 75% of their covered professional services in inpatient hospital (POS21), outpatient hospital (POS22) or Emergency Room (POS 23) are termed as Hospital based clinicians. Hospital based clinicians are required to participate in MIPS if they exceed the low volume threshold.

Non-patient Facing MIPS Eligible Clinicians:

Clinicians who bill 100 or less patient facing encounters (including telehealth services) during the determination period are considered non-patient facing. Groups who have more that 75% of their clinicians as non-patient facing clinicians are considered non-patient facing. Non-patient facing Clinicians and groups are required to participate in MIPS.

Clinicians participating in MIPS APM and Advanced APM:

Qualifying participants under Advanced APM are exempted from MIPS. The latest list of Advanced APM for 2017 is published at http://go.cms.gov/APMlist. CMS will take three snapshots – March 31st, June 30th and August 31st to determine which eligible clinicians participating in Advanced APM meet the patient (see 20% of Medicare Patients through an Advanced APM) or payment (receive 25% of Medicare Payments through an Advanced APM)  threshold to become Qualifying Participants. Partial Qualifying Participants i.e. participants in Advanced APM who do not meet the threshold (i.e. who receive 20% of payments or see 10% of patients through an Advanced APM) have a choice – to participate and receive payment adjustments or not participate and be exempted.

MIPS eligible clinicians, who do not meet the threshold for sufficient payments or patients through an Advanced APM in order to become QPs, and who practice in a MIPS APM under the APM Scoring Standard are in MIPS and have special reporting and scoring rules. The reporting and scoring rules vary by the MIPS APM. MIPS APM eligible clinicians must be listed on the MIPS APM participant list on at least one of the three participant list snapshot dates – March 31, June 30, or August 31 to be scored under the APM scoring standard. If the eligible clinician is not on the MIPS APM participant list on at least one of three snapshot dates, then they should report to MIPS as an individual or group.


About the Author:

Arnaz Bharucha is the R&D Lead for Quality Improvement and Senior Software Architect with over 17 years of experience in designing and supporting healthcare IT products for Electronic Health Record, Quality Reporting for MIPS, Meaningful Use, PQRS, PCMH, DOQ-IT etc., and professional & institutional medical billing systems. She has shouldered key responsibilities of understanding the US Healthcare industry standards, designing iPatientCare suite of products in compliance with the ONC’s Meaningful Use, designing and implementing interoperability and other healthcare Quality Reporting initiatives requirements. Under her leadership, iPatientCare has been a Qualified Registry for submitting quality measures to CMS since 2014.


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