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Quality Payment Program (QPP) Support Center

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2019 MIPS Eligibility

AA-Doc-at-computer_male.jpgHow Is 2019 MIPS Participation Determined?

Your eligibility is based on your:

  • National Provider Identifier (NPI)
  • Associated Taxpayer Identification Numbers (TINs)

A TIN can belong to:

  • You, if you’re self-employed
  • A group or practice
  • An organization like a hospital

When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination.

If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations.

Each TIN/NPI combination is evaluated for MIPS eligibility. We’ll use TINs to evaluate groups for eligibility.

MIPS Eligible Clinicians

In order to be MIPS eligible, a clinician must:

  1. Identify on Medicare Part B claims as a MIPS eligible clinician type
  2. Have enrolled in Medicare before 2019
  3. Not be a Qualifying Alternative Payment Model Participant (QP)
  4. Exceed the Performance Year 2019 low-volume threshold
    • As an individual when reporting individually, or
    • At the group level by being in a practice that exceeds the low-volume threshold when reporting as a group or virtual group, or
    • As a MIPS APM participant that exceeds the low-volume threshold at the entity level

Clinicians who don’t meet these requirements are exempt from MIPS.

MIPS Eligible Clinician Types

  • Physicians (including Doctors of medicine [KE3] [NS4], osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
  • Osteopathic practitioners
  • Chiropractors
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians or nutrition professionals

If you're one of these clinician types and aren’t exempt from MIPS, you will need to decide whether to report data to CMS as an individual, or group, or virtual group.

NPI-Look-up-Tool-icon.pngCheck Your QPP Participation Status

The Centers for Medicare and Medicaid developed a National Provider Number (NPI) Look-up Tool that clinicians can use to check your status. To use this tool, you'll simply need to enter your 10-digit National Provider Identifier (NPI) number to view your QPP participation status by performance year (PY). QPP Participation Status includes APM Participation as well as MIPS Participation.

Click here or on the tool icon on the left to access this handy tool.

Low-Volume Threshold

Beginning in Performance Year 2019, the low-volume threshold includes three aspects of covered professional services:

  1. Allowed charges
  2. Number of beneficiaries who receive services
  3. Number of services provided

Clinicians and groups fall under the low-volume threshold and are exempt from MIPS if they:

  • Bill $90,000 or less in Medicare Part B allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), or
  • Provide covered professional services for 200 or fewer Part B-enrolled individuals, or
  • Provide 200 or fewer covered professional services to Part B-enrolled individuals

If you're exempt from MIPS for Performance Year 2019, you're not required to participate.

You can choose to opt-in to MIPS if you exceed 1 or 2 of the low-volume threshold criteria. Check your status throughout the year if you make any changes that may affect your eligibility.

Who Can Opt-in And Who Can Voluntarily Report

In Performance Year 2019, you can opt-in to MIPS if you are an eligible clinician or group who exceeds 1 or 2 (but not all 3) of the low-volume threshold criteria during either review period. If you are an eligible clinician or group who opts-in to MIPS, you will receive a MIPS final score and a payment adjustment in 2021.

You can voluntarily report if you are a clinician or group that is not MIPS eligible. If you report voluntarily, you will receive a MIPS final score but no payment adjustment.

MIPS Determination Periods

Your eligibility will be reviewed twice during Performance Year 2019. Reviews will analyze CMS Medicare Part B Claims data and PECOS data from two 12-month time periods:

  • October 1, 2017 – September 30, 2018
  • October 1, 2018 – September 30, 2019

These dates have changed from previous years. CMS will use data from these dates to:

  • Determine eligibility (including whether you exceed the low-volume threshold)
  • Assign special statuses for:
    • Non-patient facing;
    • Small practice;
    • Hospital-based; and
    • Ambulatory surgical center (ASC)-based

Low-Volume Threshold Periods

Results for the first review of Medicare Part B and PECOS data will be released in December 2018. Your final eligibility results will be available in late 2019. If you joined a new practice after September 30, 2018, and assign your billing rights to a new or different TIN, your eligibility will be evaluated under that practice during the second review period. Clinicians and groups must exceed the low-volume threshold during both review periods to be eligible for MIPS.

114161569-(1).jpgClinicians in Advanced APMs

APMs allow eligible clinicians to become a Qualifying APM Participant (QP) for an opportunity to receive a 5 percent APM incentive payment and to be excluded from MIPS. To become a QP, you must receive a certain percent of your Medicare Part B payments or see at least a certain percent of Medicare patients through an Advanced APM entity at one of the determination periods (snapshots). CMS will make QP determinations using each Advanced APM entity’s Participation List at three “snapshot” dates: March 31, June 30, and August 31.

Additional Eligibility Information

Please visit the CMS Quality Payment Program website for more eligibility details.