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Quality Payment Program (QPP) Support Center

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2020 MIPS Eligibility

AA-Doc-at-computer_male.jpgHow Is 2020 MIPS Participation Determined?

Eligibility for the Merit-based Incentive Payment System (MIPS) is based on your:

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


A TIN can belong to:

  • You, if you’re self-employed,
  • A practice, or
  • An organization (such as 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.
CMS evaluates each TIN/NPI combination for MIPS eligibility and use TINs to evaluate practices for eligibility.

 

 
Use the NPI Look-up Tool to view your
2020 QPP Participation Status/MIPS Eligibility.


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MIPS Determination Period

CMS reviews past and current Medicare Part B Claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each Performance Year. Each review, or “segment,” encompasses a 12-month period.

Data from the first segment is released as preliminary eligibility. Data from the second segment is reconciled with the first segment and released as the final eligibility determination.

Clinicians and practices must exceed the low-volume threshold (LVT) during both review periods to be eligible for MIPS.
  • October 1, 2018 – September 30, 2019
  • October 1, 2019 – September 30, 2020

Learn more about the MIPS determination period.
 

Low-Volume Threshold

The low volume threshold includes 3 aspects of covered professional services:

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

You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments of the MIPS Determination Period, you:
  • Bill more than $90,000 for Part B covered professional services, and
  • See more than 200 Part B patients, and;
  • Provide more than 200 covered professional services to Part B patients.
 

MIPS Eligible Clinician Types

You are eligible to report for MIPS if you are a MIPS eligible clinician type (and also meet all the other requirements in the next section). If you’re not one of these clinician types, you’re exempt from reporting.
 
  • Physicians (including doctors of medicine, 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
 

MIPS Eligible Clinicians

There are different ways to become a MIPS eligible clinician, depending on whether you’re reporting as an individual, part of a group, part of a MIPS Alternative Payment Model (APM), or part of a virtual group. If you don’t meet the requirements in this section, you’re exempt from MIPS.

Learn more about what to do next as a MIPS eligible clinician.
 

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In order to be MIPS eligible as an individual clinician, you must:


If you’re MIPS eligible as an individual, you’re required to report for MIPS.

 

MIPS Eligible as Part of a Group

In order to be MIPS eligible as part of a group, you must:

If you’re MIPS eligible in your group, you’ll receive a score and payment adjustment based on group reporting when the group reports.
 

MIPS Eligible in a MIPS APM

The fourth snapshot date of December 31 is for full TIN APMs (Medicare Shared Savings Program). The APM scoring standard offers a special, minimally-burdensome way of participating in MIPS for:

  • Eligible clinicians in APMs who do not meet the requirements to become QPs and are therefore subject to MIPS
  • Eligible clinicians who meet the requirements to become a Partial QP and are therefore able to choose whether to participate in MIPS


To be considered part of the APM Entity for the APM scoring standard, you must be on an APM Participation List for at least 1 of the 3 snapshot dates of the performance period. Otherwise, you must report to MIPS under the standard MIPS methods.

If you participate in a MIPS APM, then you may be MIPS eligible in a MIPS APM. To be eligible in a MIPS APM you must:


If you’re MIPS eligible in a MIPS APM, you’re required to report some data as part of that MIPS APM.
 

MIPS Eligible in a Virtual Group

If you participate in a virtual group, then you may be MIPS eligible in a virtual group. To be eligible in a virtual group you must:


If you’re MIPS eligible in a virtual group, the virtual group is required to report your data.
 

Opt-in Eligible Clinicians

If you’re an opt-in eligible clinician, you are not required to participate in and report to MIPS, but during the submission period, you may elect to opt-in to MIPS.

Learn more about opting-in to MIPS.
 

Opt-in Eligible as an Individual

You can elect to opt-in to MIPS as an individual if you:

 

Opt-in Eligible as Part of a Group

You can elect to opt-in to MIPS as a group if the group:

  • Contains at least one clinician identified as a MIPS eligible clinician type on Medicare Part B claims,
  • Contains at least one clinician who enrolled in Medicare before 2020,
  • Does not contain only QPs, and
  • Exceeds at least one but not all 3 of the low-volume threshold criteria at the group level.

If the practice opts-in to report as a group, the clinician does not need to opt-in to receive the group score and payment adjustment.
 

Clinicians in Advanced Alternative Payment Models (AAPMs)

Sufficient participation in an Advanced APM allows you to achieve QP status and therefore receive a 5% APM incentive payment and be excluded from MIPS.

CMS will make QP determinations using each Advanced APM entity’s Participation List on 3 snapshot dates: March 31, June 30, and August 31.
Learn more about APM snapshots.
 

MIPS Eligible Practices

If a practice is MIPS eligible, it may report for all clinicians in the practice as a group. In that case, you will receive a score and a payment adjustment based on that group reporting (unless you also report as an individual, in which case you’ll receive the higher of the 2 scores).

AdobeStock_324106320.jpegIn order for a practice to be MIPS eligible, it must:

 

Opt-in Eligible Practices

If a practice is opt-in eligible, they can elect to opt-in and report as a group on behalf of all clinicians in the practice. If your practice opts-in and reports as a group, you will receive a score and a payment adjustment based on that group reporting (unless you elect to opt-in and report as an individual, in which case you’ll receive the higher of the 2 scores).

If a practice opts-in and reports as a group, individual clinicians don’t need to opt-in to receive the group score and payment adjustment.
A practice can elect to opt-in to MIPS and report as a group if it:

 

Additional Resources