MIPS Program FAQ

Legal Disclaimer: Statements contained in this training are WebPT’s interpretation of the QPP rules. The information contained in this training is provided on an “as is” basis with no guarantees of accuracy, completeness, or timeliness and without warranty of any kind, express or implied. The information provided in this training is general in nature and should not be considered legal, consulting, or professional advice. QPP Participants should consult with professional advisors and/or the Center for Medicare and Medicaid Services for advice concerning specific information about QPP.

General Questions

What is MIPS?

The Merit-Based Incentive Payment System (MIPS) is one of two tracks in the Quality Payment Program (QPP) currently administered by the Centers for Medicare and Medicaid Services (CMS).

PTs, OTs, and SLPs who participate in the program are required to complete two of the four performance categories: Quality and Improvement Activities.

How do I check if I need to participate in MIPS?

Use the QPP MIPS Eligibility Tool to determine your MIPS eligibility status for the selected performance year.

All you need to do is type in your NPI; then, Quality Payment Program (QPP) will pull your information from the most recent 12-month determination period and tell you whether or not you’re required to participate in MIPS.

When you create a login for QPP, you can also check the MIPS status of all providers within a practice.

What does reporting as a group mean?

Reporting as a group means that every eligible provider associated with your EIN is required to participate, even if they are not individually mandated. In this instance, eligible providers are PTs, OTs, and SLPs that are credentialed with Medicare.

Remember: Participation in MIPS includes reporting quality measures for every eligible patient, regardless of insurance type. For more information, please see the highlighted text on page 10 of the 2018 Quality Performance Category Fact Sheet.

How does MIPS impact my reimbursements?

At the end of each calendar year, eligible providers submit their relevant data to CMS and receive a MIPS score—ranging from 0-100 points—before the start of the payment year. That score determines the capped adjustment (either positive or negative) the clinician receives from Medicare two years later. For example, a provider’s 2022 score will affect their 2024 adjustment.

The potential bonus is a 9% increase, and the maximum penalty is a 9% reduction.

Note: Due to the budget-neutral requirements of this program, positive MIPS adjustments have historically not exceeded 2%

If a provider leaves during the year, will our clinic be penalized for their MIPS score?

The MIPS score of a provider who has left your practice will only affect your clinic if you elected to report as a group. If your clinic is enrolled as individuals, their MIPS score will follow them to their next place of employment.

What is the 2023 MIPS Performance Period?

The 2023 MIPS performance period is from January 1, 2023, to December 31, 2023. Please see the timeline below for additional details.

Can I turn on MIPS reporting for only certain therapists, or do I have to turn it on for all therapists?

WebPT’s MIPS product will allow you to “turn on” the reporting for certain therapists (i.e., only those who meet all of CMS’s eligibility criteria). You can also enable reporting for all therapists.

What are the requirements for successful MIPS participation?

Success requires two distinct efforts, which should occur concurrently.

You’ll need to submit all applicable Quality measures for at least 20 cases with at least 70% completeness.
You’ll need to select and attest to approved Improvement Activities for at least 90 days per activity.

Which visits types will have MIPS reporting?

Typically, expect to complete MIPS measures for the initial evaluation and re-evaluation notes for PTs/OTs. One notable exception is the IROMS measures; using IROMS measures requires two completed OMTs (Outcome Measurement Tools) to trigger reporting.

What is an eligible visit?

An eligible visit is defined as any visit within the current performance period that meets the specifications and patient qualifications established in the Measure Specification Guide. Providers can report for any eligible visit regardless of if they or another therapist has reported on the measure during the reporting period. The following examples apply to eligible visit reporting:

PT John sees a patient for a neck case on 1/1/23 and reports on measure 155. The patient comes back on 4/1/23 for a new case and sees PT John again. Because the visit is within the current performance period, the visit is eligible for MIPS reporting and PT John must report on 155 again.
PT John sees a patient on 1/1/23 for neck pain and reports on measure 134. The patient also sees OT Maria on the same day. Because the visit is within the current performance period, the visit is eligible for MIPS reporting and Maria must report on 134.

If our clinic is interested in hiring a therapist mid-year, is there a way to determine their current MIPS score to help influence our decision?

No. MIPS scores for the 2022 performance period will not be calculated until July 2023. There are some registries that offer real-time tracking that can provide a general idea of what their current score is, but the therapist will have had to be using one of those registries at their previous place of employment. Additionally, they will have had access to the tracking features of that registry, which is usually reserved for Clinic Admins.

Our clinic treats a large number of children. Will we lose points because of their ineligibility?

No. If a patient does not meet the criteria for a specific measure, they are not counted against you.

What happens if a patient is initially evaluated by a therapist that is mandated to report MIPS but a non-enrolled therapist completes their re-evaluation?

MIPS reporting is determined by a therapist’s participation status, not a patient’s eligibility for each measure. CMS will only be looking at evaluations and re-evaluations that are completed by a MIPS-eligible therapist.

If my clinic employs seasonal therapists, how would I handle reporting MIPS? Should we report as a group or as individuals?

We recommend that only individuals who are mandated to report participate this year. If your entire organization is mandated, you can elect to report as a group if you think that you’d do better as an average, than individually. If not everyone in your organization is mandated to report, then only the individuals who are required should report.

Quality Measures

What quality measures will I have access to?

Keet Patient Reported Outcomes (PRO):

Measure HM7: Functional Status Change for Patients with Vestibular Dysfunction
Measure IROMS 13: Functional Status Change for Patients With Lower Extremity Functional Status Deficit
Measure IROMS 11: Functional Status Change for Patients with Knee Functional Status Deficit
Measure IROMS 15: Functional Status Change for Patients With Neck Functional Status Deficit
Measure IROMS 17: Functional Status Change for Patients With Low Back Functional Status Deficit
Measure IROMS 19: Functional Status Change for Patients with Upper-limb Functional Status Deficit

WebPT EMR Process Measures:

Measure 126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation
Measure 127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
Measure 128: Body Mass Index (BMI) Screening and Follow-Up
Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Measure 155: Falls: Plan of Care
Measure 181: Elder Maltreatment Screen and Follow-Up Plan
Measure 182: Functional Outcome Assessment
Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Which measures were added or removed for the 2022 reporting year?

Added:

Quality Measure 048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
Quality Measure 178: Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.
Quality Measure 487: Screening for Social Drivers of Health: Percent of beneficiaries 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

Additionally, some measure descriptions were updated:

Quality Measure 050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older. CMS is adding coding for OT to support this measure since it is applicable to their scope of care.
Quality Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. CMS finalized their proposal to (a) add a grace period after the end of the encounter to document the follow-up plan, which would allow more flexibility in the clinical workflow giving clinician’s time for documentation, and (b) to screen for new cases of depression in patients who have never had a diagnosis of depression or bipolar disorder, as well as to clarify the timing requirements of diagnoses for the measure exclusions.
Quality Measure 181: Elder Maltreatment Screen and Follow-Up Plan. CMS finalized their proposal to revise the measure description and revise the measure denominator.
Quality Measure 182: Functional Outcome Assessment. CMS finalized their proposal to revise the measure description and numerator as well as update the numerator definition, numerator instructions and numerator options.
Quality Measures 217 – 222 and 478: CMS finalized their proposal to update the measure definition to allow for utilization of a crosswalk, potentially reducing burden for clinicians and their patients who prefer an alternative (legacy) PROM for reporting of this quality measure.
Quality Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. CMS finalized their proposal to allow a lookback of 6-months for tobacco cessation intervention prior to the current measurement period.
Quality Measure 431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling. CMS finalized their proposal to update the denominator exclusion, denominator criteria, numerator definition and numerator options.

Removed:

Quality Measure 130: Documentation of Current Medications in the Medical Record. CMS has finalized their proposal to remove this measure from Medicare Part B claims collection type. CMS will retain this measure for eCQM Specifications and MIPS CQMs Specifications collection types.

How many quality measures do I need to submit?

You should submit at least six measures: one outcome measure and five process measures. If you collect data for more than six measures, your best six will be sent to CMS. Each measure is worth a maximum of 10 points, creating a category point cap of 60 points.

Remember, your highest-scoring measure may not be your highest performing, as the score is related to your performance against the benchmark.

Why do I have to submit quality measures for all patients, regardless of insurance type?

Anyone submitting through a qualified registry must complete quality measure reporting for every patient, not just Medicare patients, as outlined in the 2017 Final Rule. As Healthmonix, our MIPS reporting partner, is a QCDR, we’ve configured our MIPS functionality to comply with this rule. If you have purchased MIPS reporting through the WebPT EMR, you will be prompted to complete quality reporting for every patient.

For more information, please see the highlighted text on page 10 of the 2018 Quality Performance Category Fact Sheet.

What if I have less than 6 applicable quality measures?

In the case that a MIPS participant has fewer than six measures applicable, the participant must submit every applicable measure. Specifically, if you are an SLP, you must report on each of your four applicable measures (130, 181, 182, and 226).

I read that each measure is worth 10 points, why are some listed as 3 or 7 points?

Measures with maximum achievable point values of less than 10 meet one of the following criteria:

The measure is “topped out,” which indicates the median performance rate is 95% or higher for those who submitted the measure. These measures are given a max value of 7 points. Topped out measures are still available for bonus points.
The measure does not have a benchmark. Because these measures don’t have enough data (yet) to create a benchmark, participants cannot receive a performance rate for reporting these measures and thus are given points for simply completing the measure and contributing to the benchmarking data. Measures without a benchmark are capped at 3 points.

How are my Quality measures reported?

You'll submit your quality measures through Keet once CMS begins accepting submissions after December 31, 2023.

Improvement Activities

What are the available Improvement Activities?

The QPP has more than 100 approved activities; you can view the full list here. However, since MIPS is a physician-focused program, not all activities may be relevant to your organization. To simplify things, we’ve created a list of the 15 most applicable activities and have compiled them into this document.

What do I need to submit to prove I’ve completed the activities?

You do not need to provide proof of completion. That being said, you should maintain thorough documentation of everything you’ve done in case of an audit.

How are my activities reported?

There are 2 ways WebPT Members can attest to Improvement Activities for the 2023 performance period:

Final Score

Your MIPS Final Score

Your Final score is a calculated value determined by combining your scores in the Quality and Improvement Activities categories. These categories are weighted, with Quality accounting for 85% of the total MIPS score and Improvement Activities for 15%. Therefore, Quality is the most influential category in your overall score.

It’s important to understand that unlike PQRS, which was a “pass or fail” program, MIPS scoring involves a complicated points system, and those points are determined based on a wide variety of factors, including individual performance against benchmarks—not solely on successful measures reporting.

For more information on how scores are calculated, click here.

Note: For practices with 15 or fewer providers, Quality and Improvement Activities have been reweighted at 50% each for the 2022 Reporting Period.

What is the minimum score I must achieve to avoid the penalty?

MIPS participants must score at least 75 points to avoid a negative payment adjustment.

What does a budget neutral program mean?

Note: This is pulled from the MIPS Scoring 101 guide and updated for the 2022 thresholds.

There are two MIPS payment adjustments. The first payment adjustment is calculated in a way to ensure budget neutrality. Clinicians who earn exactly 75 points earn a neutral adjustment. Clinicians above the performance threshold earn a positive payment adjustment, which is subject to a scaling factor. Clinicians below the performance threshold will be subject to a negative adjustment. The maximum negative adjustment is 9%.The second round of MIPS payment adjustments will be determined by the distribution of final scores across MIPS eligible clinicians and the performance threshold. More MIPS eligible clinicians with final scores above the performance threshold means the scaling factors would decrease because more eligible clinicians receive a positive MIPS payment adjustment. In this case, the maximum positive payment adjustment factor could be considerably less than 9%. More MIPS eligible clinicians with final scores below the performance threshold means the scaling factors would increase because more eligible clinicians would have negative MIPS payment adjustments and relatively fewer eligible clinicians would receive positive MIPS payment adjustments.

How does my final score align with an adjustment segment?

Does a MIPS score follow the provider NPI?

Yes. MIPS is tracked and calculated by individual provider NPI, so the associated payment adjustments are always applied at the individual level (even if the individual moves to another practice or group).

Do you have any further MIPS resources?

Yes. Review the following blog articles for more information on MIPS: