COVID-19 AWARENESS: We’re committed to sharing the latest Coronavirus information available. Visit our information center for news and information.
Slide1 background qpp background

Quality Payment Program (QPP) Support Center

360 Support Learn More

2021 MIPS Eligibility

How Is 2021 MIPS Participation Determined?

Your eligibility is based on your:storyblocks-doctors-and-nurses-in-healthcare-team-with-arms-crossed-in-a-row-in-hospital_BjTaOcFUV.jpg

  • 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 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.

We evaluate each TIN/NPI combination for MIPS eligibility and use TINs to evaluate practices for eligibility.

Navigate to:  
 
Use the NPI Look-up Tool to view your
2021 QPP Participation Status/MIPS Eligibility.


NPI-Look-up-Tool-icon.png
 



MIPS Determination Period

We review 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”, looks at 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.
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 200 or more covered professional services to Part B patients.

If you start billing Medicare Part B claims under a practice’s TIN during segment 2, your eligibility at that practice will be based solely on the results from segment 2.
 

MIPS Eligible Clinician TypesAdobeStock_217329495.jpeg

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 excluded 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


 

MIPS Eligible as an Individual

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

  • Be identified as a MIPS eligible clinician type on Medicare Part B claims,
  • Have enrolled as a Medicare provider before 2021,
  • Not be a Qualifying Alternative Payment Model Participant (QP), and
  • Exceed the low-volume threshold as an individual.


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

 
 

MIPS Eligible as Part of a Group

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.
A practice is opt-in eligible as a group if it:

  • Has at least one clinician who:
  • Exceeds 1 or 2 of the 3 low-volume threshold criteria at the group level.
  • If your practice opts-in as a group, you will receive a score and a payment adjustment based on that group reporting (unless you elect to opt-in as an individual, in which case you'll receive the higher of the 2 scores). If the practice opts-in to report as a group, you don't need to opt-in to receive the group score and payment adjustment.


 

MIPS Eligible in a MIPS APM

Beginning with PY 2021, we will no longer conduct low-volume threshold determinations at the APM Entity level. As of PY 2021, the same rules for MIPS eligibility apply to APM participants as to other MIPS eligible clinicians.

Qualifying APM Participants (QPs), and Partial QPs that elect not to report to MIPS, are not required to report to MIPS. You may verify your eligibility in the QPP Participation Status Lookup Tool. MIPS eligible clinicians who participate in a MIPS APM have the option to report the APM Performance Pathway (APP).

 

MIPS Eligible in a Virtual Group

IIf 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:AdobeStock_117751819.jpeg

  • Be identified as a MIPS eligible clinician type on Medicare Part B claims,
  • Have enrolled as a Medicare provider before 2021,
  • Not be a QP, and
  • Participate in a practice that exceeds the low-volume threshold and is part of a virtual group.
 

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, then you’re 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 opt-in

 

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

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.
A practice is opt-in eligible as a group if it:

  • Has at least one clinician who:
  • Exceeds 1 or 2 of the 3 low-volume threshold criteria at the group level.

If your practice opts-in as a group, you will receive a score and a payment adjustment based on that group reporting (unless you elect to opt-in as an individual, in which case you'll receive the higher of the 2 scores). If the practice opts-in to report as a group, you don't need to opt-in to receive the group score and payment adjustment.

 

Qualifying APM Participants (QPs)

If you sufficiently participate in an Advanced Alternative Payment Model (APM), you may achieve QP status which excludes you from MIPS participation and makes you eligible for a 5% APM incentive payment. Additionally, Partial QPs may elect to participate in MIPS.
If you don’t achieve QP status, or Partial QP status that elects not to participate in MIPS, and are a MIPS eligible clinician, you will need to participate in MIPS.

We will make QP determinations using each Advanced APM entity’s Participation List at 3 snapshot dates: March 31, June 30, and August 31.

Learn more about APM Determination Periods


 

What Might Cause My Eligibility to Change?

  • AdobeStock_106433419-(2).jpegJoining a new practice or APM entity
  • You may be required to report if you bill Medicare Part B claims under a new practice/TIN in segment 2 or join an APM entity in later snapshots.
  • Changing provider type/specialty code from segment to segment
  • Changing your provider type or specialty code from segment to segment could affect your eligibility.
  • Billing data for Segment 1 but not Segment 2
  • If you stop billing Medicare Part B claims under a specific practice (TIN) during segment 1, and have no Medicare Part B claims billed during segment 2 for that practice, you will be removed entirely from the practice’s list of clinicians.
  • Falling below the low-volume threshold in MIPS Segment 2
  • You will not be eligible to participate if you fall below all 3 elements of the low-volume threshold in segment 2.
  • Learn more about APM Determination Periods
  • Dropping out of an APM entity during the Performance Year
  • We assess eligible clinicians for QP Status at the APM Entity level, based on either the payment amount or patient count method. We assess eligible clinicians individually only when the Advanced APM includes eligible clinicians only on an Affiliated Practitioner List, or when the eligible clinician participates in multiple Advanced APMs and do not achieve QP Status at the APM Entity level. Calculations for eligible clinicians on an Affiliated Practitioner List will be posted each snapshot. All three individual snapshot scores will be calculated for those in more than one APM Entity, the most favorable of the three scores will be posted as part of the third snapshot results.
  • You will maintain your QP status unless the Advanced APM Entity’s participation in the Advanced APM is voluntarily or involuntarily terminated prior to the end of the QP Performance Period.
  • Changing QP status
  • Your QP status can change at each APM snapshot depending on whether the APM Entity or individual score meets or exceeds the QP thresholds.
 

Learn more about APM Determination Periods


 

Additional Resources