MIPS 2019 – What You Need to Know About the Quality Payment Program

by Jayne (Collard) Engelking | Dec 26, 2018 | , , , ,

A summary of the key 2019 MIPS changes

This post was originally published on Dec. 1, 2017 and was updated on Dec. 26, 2018 to reflect the 2019 QPP Final Rule.

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released its 2019 Quality Payment Program (QPP) Final Rule, detailing its changes to the Merit-Based Incentive Payment System (MIPS) and the 2019 Physician Fee Schedule (PFS).

This whopping 2,378-page document and the mouthful of acronyms that come with it can be more than a little difficult to decipher. To help you set your practice up for success in 2019, let’s break down some key points to know about the new rules and regulations for value-based payment.

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Even more than in previous years, CMS is actively trying to reduce physician burnout and the regulatory burden that data collection and MIPS reporting place on clinicians. As part of its Patients Over Paperwork initiative, it aims to streamline the 2019 MIPS program, implement meaningful measures, promote interoperability, and support the needs of small and rural practices.

Ultimately, CMS’ healthcare goal is to improve patient outcomes and reduce overall costs for the US health system through value-based care. In fact, it expects the changes to reduce administrative costs by $87 million in 2019 and $843 million over the next 10 years. In addition, it anticipates that the changes will save physicians 21 million hours over the next decade, beginning in 2021.

At the same time, CMS has made many of the requirements more difficult, aiming to challenge providers more as we arrive at the year three of the transition period. Last year, some organizations actually criticized CMS for being too lenient with its MIPS reporting requirements as it attempted to ease providers into the MIPS program. With the harder rules this year for MIPS, CMS predicts a median MIPS 2019 score of 78.72, 11.5 percent lower than the median 2017 MIPS score of 88.97.

Hopefully, CMS is correct that these 2019 QPP changes will have a lasting positive impact on the program’s participants and beneficiaries overall, even if they create some short-term hardships for clinicians. But what could all these changes mean for your practice on a more specific level? Let’s take a look. 

Adjustment rises to 7 percent

For 2019, eligible clinicians’ MIPS performance will determine whether they receive a positive or negative payment adjustment of up to 7 percent on their 2021 Medicare reimbursements for covered professional services. This is up from 5 percent in 2018 and 4 percent in 2017. For a practice that bills $1,500,000 in Medicare each year, this could determine whether you take home $1,605,000 or $1,395,000 in 2021. That’s a $210,000 difference.

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), MIPS is required to be budget neutral. Because of this, the exact amount of the adjustment can vary depending on the number of providers who end up in the bonus and penalty pools. Currently, CMS forecasts distributing a larger amount of incentives for MIPS 2019 than MIPS 2018—approximately $390 million.

With the stakes getting higher, it’s more important than ever to make sure your practice has the right technology and processes in place to collect the necessary data and work towards earning a positive adjustment.

Performance threshold doubles

In 2019, the MIPS performance threshold will rise from 15 to 30 points. Depending on the tools you have and the resources your practice is able to put into MIPS 2019 reporting, this may still be a relatively easy target to hit.

However, if you miss the threshold, there’s a high price to pay—all qualifying clinicians whose final scores are below the threshold will be subject to the negative payment adjustment of up to 7 percent on their Medicare reimbursements for covered professional services.

With the MIPS performance threshold projected to continue increasing by 15 points each year until 2022, it’s important to have tools at your fingertips making it simple to track your estimated score. Moreover, it’s important that the data is updated in near-real time, letting you track changes on a daily basis, not just per quarter or per month. That way, you can help avoid being unpleasantly surprised at the end of the year to find that you fell below the threshold.

Exceptional performance threshold rises

To be eligible for a share of the $500 million exceptional performance bonus (separate from the regular $390 million adjustment pool), MIPS 2019 participants will need to score a minimum of 75 MIPS points. This is a relatively small increase—just five points—but it will likely reduce the number of MIPS 2019 participants that qualify for the bonus. That, in turn, will mean a bigger piece of the pie for each exceptional performer.

If your practice is determined to achieve exceptional performer status, it may be worth considering a MIPS advisory service to help you work toward achieving your goal. With an experienced, CMHP-certified advisor monitoring your performance and providing guidance on how to improve, you may be able to increase your chances of snagging the additional bonus.

New eligible clinician types added

While many clinicians have found MIPS participation to be a burden, others who were not eligible were disappointed to miss out on the opportunity to earn a positive adjustment. So CMS added the following to its list of eligible clinician types:

  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered dietitian or nutritional professionals

CMS projects that this will increase the number of participating clinicians from 620,000 to 800,000. That, in turn, would decrease the bonus or penalty amount for each individual because the amount will be split among a larger pool.

Low-volume opt-in option added

CMS had already put in place low-volume exemptions so that clinicians with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries don’t have to report MIPS. Its aim was to avoid creating an excessive regulatory burden for physicians who barely participate in Medicare. This year, it added a new low-volume component: ≤200 covered professional services.

For 2017 MIPS, clinicians below the low-volume threshold for individual MIPS reporting were often able to become eligible by reporting as part of a group. As a result of this, the number of participating clinicians for last year far surpassed CMS’ expectations.

In an attempt to offer more flexibility to clinicians eager to scoop up incentive payments, CMS has added the option for clinicians, groups or virtual groups to opt into MIPS 2019 via CMS’ official process if they meet at least one (but not all three) of the low-volume criteria.

As with 2018, the virtual groups option allows clinicians at small practices to take advantage of the benefits of group MIPS reporting while remaining independent. Members of a virtual group may opt into MIPS if any prospective member of the virtual group meets one, but not all, of the low-volume threshold criteria. If you’re interested in joining a virtual group, be sure to have your designated group representative email your virtual group election to MIPS_VirtualGroups@cms.hhs.gov by December 31, 2018.

Category weights change

For 2019, the MIPS Cost category weight will increase by 5 percent to comprise 15 percent of physicians’ total scores. Meanwhile, Quality will go down to 45 percent from 50 percent. Promoting Interoperability and Improvement Activities remain at 25 percent and 15 percent, respectively.

MIPS 2019 quality measures modified

For 2019 MIPS, CMS continues its efforts to turn its quality measures into valuable indicators of healthcare quality rather than simply meaningless boxes for doctors to check.

As part of its Meaningful Measures initiative, CMS is moving towards outcome-based measures and away from process-based and topped-out measures. A topped-out measure is defined as one in which average scores are so high that it’s difficult for CMS to meaningfully rank providers. Removing topped-out measures will reduce the points many clinicians earn for Quality, but it fits with CMS’ goal of making MIPS more challenging.

For 2019, CMS removed 26 MIPS quality measures, including the following specialty-specific measures:

  • Dermatology – 224: Melanoma Overutilization of Imaging Studies
  • Ophthalmology – 140: Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
  • Gastroenterology – NQF068: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
  • Otolaryngology – 276: Sleep Apnea – Assessment of Sleep Symptoms
  • Otolaryngology – 278: Sleep Apnea – Positive Airway Pressure Therapy Prescribed
  • Otolaryngology – 334: Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)

Eight new measures were added, including four patient-reported outcome measures and six high-priority measures. In addition, CMS has moved the six-point small practice bonus to the numerator of the Quality category. Moreover, in 2019 MIPS, reporting claims-based measures will only be allowed for clinicians in small practices (15 or fewer clinicians).

Other changes include allowing clinicians to report through multiple collection types, such as CEHRT and a specialty registry. If a clinician submits one measure through multiple collection types, the one with the highest score will be counted in their final score. However, the CMS Web Interface cannot be used in conjunction with another collection type.

Amid this wide array of changes, it’s important to partner with a technology vendor that stays on top of the updates. Your EHR should also allow you to capture measures efficiently within your existing workflow, helping you meet the CMS reporting requirements without adding lots of time and clicks.

Promoting Interoperability gets overhauled

As part of its goal to challenge providers more in MIPS 2019, CMS completely redid the measures and scoring methodology for the Promoting Interoperability category, formerly known as Advancing Care Information. This new performance-based scoring is designed to foster meaningful data exchange and access among providers, health organizations and patients, while staying in line with the new Medicare Promoting Interoperability Program for hospitals.

Almost all the 2018 MIPS measures were either removed or modified, including the removal of patient engagement measures such as View, Download or Transmit that require actions by patients rather than providers. CMS has added four new measures, including Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement.

Measures now fall under one of four objectives: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Unless an eligible clinician or group is able to claim an exclusion, they must report certain measures from each objective. Each measure will now be scored based on clinician performance, as determined by the submission of a numerator or denominator or a yes/no submission where applicable.

Episode-based cost measures added

The Cost category, new to MIPS in 2018, is the only category for which providers do not have to report data. That’s because CMS bases scoring on the clinician’s Medicare claim submissions. As in 2018, the Cost category will look at Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary (MSPB).

This year, CMS also added eight episode-based measures, some of them impacting orthopedic surgeons, gastroenterologists and ophthalmologists:

  • Elective Outpatient Percutaneous Coronary Intervention (PCI) (Procedural)
  • Knee Arthroplasty (Procedural)
  • Revascularization for Lower Extremity Chronic Critical Limb Ischemia (Procedural)
  • Routine Cataract Removal with Intraocular Lens (IOL) Implantation (Procedural)
  • Screening/Surveillance Colonoscopy (Procedural)
  • Intracranial Hemorrhage or Cerebral Infarction (Acute inpatient medical condition)
  • Simple Pneumonia with Hospitalization (Acute inpatient medical condition)
  • ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) (Acute inpatient medical condition)

These measures were field tested last year, so CMS will begin scoring them immediately.

Publishing scores on Physician Compare

Certain data on providers’ participation in quality initiatives is already available to the public on CMS’ Physician Compare website, but 2017 QPP data will be public as well beginning on January 1st. Mandated by the Affordable Care Act (ACA), Physician Compare is designed to serve as an informational tool for patients while giving providers another reason to participate in value-based care programs.

CMS has built in a two-year lag between when data is collected and when it is displayed on Physician Compare, so MIPS 2019 performance will not be visible until 2021. For a few months, CMS has been giving providers the chance to preview their profiles before the 2017 data becomes public in 2019. However, at this point, it’s too late to change anything since the data is from last year.

To help providers put their best foot forward, CMS has stated that new Quality and Cost measures will not be publicly reported for the first two years they are used. For MIPS Promoting Interoperability, clinicians and groups that do well will get a “successful” stamp on their profiles.

As with the 2018 MIPS reporting year, CMS will be developing an Achievable Benchmark of Care (ABC™) methodology, translating MIPS performance into 5-star ratings on Physician Compare. These will first be visible for 2018 data in 2020.

To avoid being surprised by the score you see on your Physician Compare profile when the preview period opens up, it helps to have near-real-time tools to track your MIPS performance during the reporting year. That way, you can make adjustments if needed before it’s too late to try to improve your score.

2015 CEHRT required

For 2018, CMS showed leniency to providers by allowing them the option to continue using 2014 Edition ONC Certified Electronic Health Record Technology (CEHRT) to report MIPS. For 2019, however, 2015 CEHRT is mandatory for reporting EHR measures. If, like most providers, you’re already using 2015 CEHRT, this will not be an issue.

However, CMS acknowledges that this will force some providers (especially the new eligible clinician types) to adopt a different system. To help mitigate the hardships this could cause, it kept the reporting periods for each MIPS 2019 category the same as in 2018. Promoting Interoperability and Improvement Activities, the categories most driven by EHR utilization, remain at 90 days, while Cost and Quality remain at a full year. CMS hopes that the 275 days during which providers are not reporting PI and IA will free them up to switch to 2015 CEHRT if needed. Providers still have the option to report up to a full year of PI and IA data if they wish.


To sum it all up, CMS is significantly ramping up the reporting requirements for 2019. As part of its efforts to make MIPS more valuable to the overall healthcare system, CMS is challenging providers more while seeking to ease the MIPS reporting burden where possible.

For additional details on what’s changing, visit CMS’ Quality Payment Program website or read the Quality Payment Program 2019 Fact Sheet.

At Modernizing Medicine®, we work with practicing physicians to create industry-leading tools and personalized services that can help make it easier to understand the regulations, collect MIPS data, track your score and submit to CMS.

Interested in learning more about our MIPS scorecard and MIPS Advising service?

Jayne Engelking (Collard)

Jayne Engelking (Collard)

Program Manager

Jayne Engelking (Collard) is the Program Manager and a Certified MIPS Health Professional (CMHP). Prior to her almost seven years at Modernizing Medicine, Jayne was a MA at a wonderful family owned dermatology practice in Durango, CO. Jayne has a partial masters in Mental Health Counseling and currently leads an EMAzing team of MIPS Advisors for both EMA and gGastro while living and working out of Colorado.

Jayne recently got married and honeymooned in Croatia and Ireland. Croatia is now her and her new hubby’s favorite place they have ever been to!

10 Changes to Know: 2018 QPP Final Rule

The content below was originally published on Dec. 1, 2017.

In the new 2018 Quality Payment Program (QPP) Final Rule, the Centers for Medicare and Medicaid Services (CMS) has outlined a wide range of changes to its value-based care programs. Are you and your EHR vendor prepared?

2018 marks the second year of the Merit-Based Incentive Payment System (MIPS), and the requirements are definitely ramping up and posing more of a challenge. However, CMS’ MIPS is nothing to be too scared of—as long as your practice has the right technology to streamline your MIPS data collection and submission.

So what’s specifically changing? In case you don’t have time to read all 1,653 pages of the 2018 Quality Payment Program Final Rule yourself, here’s an overview:

1. Payment adjustment increases to +/-5%

CMS is raising the stakes for 2018—if only by 1%. This past year, providers could earn up to a 4% positive or negative adjustment on their Medicare reimbursements (applied in 2019) depending on their MIPS performance, but that percentage increases to +/-5% for 2018 (applied in 2020).

This means that if your practice bills $1,000,000 in Medicare per year, then your MIPS performance could earn you a $50,000 bonus or penalty in 2020. And since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS’ MIPS program to be budget-neutral, that bonus could increase by an additional adjustment factor if more providers earn a negative adjustment than anticipated.

2. Low-volume threshold goes up

In 2018, providers with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries will not be subject to MIPS. Compared to the 2017 MIPS threshold of ≤$30,000 in charges or ≤100 beneficiaries, this is a significant increase. The 2017 threshold already exempted a large proportion of Medicare Part B providers, and this 2018 change will exempt even more.

3. Performance threshold increases to 15

For the 2017 performance period, providers could avoid the negative Medicare payment adjustment in 2019 with a MIPS Composite Performance Score (CPS) of just three points. This could be easily achieved by submitting either one Quality measure, one Improvement Activity (IA) or all Promoting Interoperability (PI; formerly Advancing Care Information) base measures.

For the 2018 performance period, you’ll need 15 points or more to avoid the negative adjustment in 2020. While this is a 400% increase, it could still be as simple as completing 2-3 Quality measures, four IAs or all PI base measures. For practices that are already strong MIPS performers, this minimum threshold change will have little impact. The exceptional performance threshold required for positive adjustments will remain at 70 points.

4. Cost category takes effect

In its first year, MIPS scored providers on three categories: Quality, PI and IA, with the Cost category weighted at 0%. Starting in 2018, MIPS adds a 10% weight for the Cost category, which is based on Medicare Part B claim submissions. Because eligible clinicians (ECs) already submit this claims data to CMS, they will not need to send any additional data to report the Cost category.

More specifically, Cost scoring is based on the Medicare spending per beneficiary (MSPB) and the total per capita costs for all attributed beneficiaries measure. This could have an enormous impact on the scores of clinicians who frequently prescribe expensive Part B drugs, such as ophthalmologists, rheumatologists and oncologists. To learn more, check out our deep-dive blog post on how the 2018 MIPS Cost category works.

5. Category weights change

The Quality category was originally proposed to remain at 60% of the MIPS CPS in 2018, with Cost not factoring in until 2019. However, the 2018 QPP Final Rule introduced Cost this year at 10%, so CMS is decreasing Quality’s weight to 50% to compensate. The PI and IA categories will remain at 25% and 15%, respectively.

6. Virtual groups participation option introduced

With many small practices concerned about their ability to succeed independently under MACRA and MIPS, CMS has introduced a virtual groups option that can allow ECs to benefit from group reporting without actually joining a group or selling their practice.

To form a MIPS virtual group in the Quality Payment Program, a solo practitioner or group of 10 or fewer ECs must come together virtually with at least one other solo practitioner or group to participate in MIPS for a year. Group members do not need to be in the same specialty or location. CMS simply requires that they report as a group across all performance categories and meet the same MIPS requirements as non-virtual groups.

Once MIPS reporting is complete, all group members will receive the same score and Medicare payment adjustment percentage. The idea is that by sharing the reporting burden and combining their strengths, providers may be able to earn higher MIPS scores together than individually.

The deadline for selecting the 2018 MIPS virtual group option is December 31, 2017, so time is running out if you’re interested in participating. To learn more, download CMS’ MIPS Virtual Groups Toolkit.

7. Extreme and uncontrollable circumstances exemption added

In the wake of Hurricanes Harvey, Irma and Maria, CMS has added new hardship exemptions for physicians who cannot meet MIPS reporting requirements due to hurricanes, natural disasters or public health emergencies. These will apply to the 2017 Quality Payment Program performance year as well as 2018, and the application deadline for hardship exceptions will be December 31 each year.

How does it work? If affected clinicians don’t submit any data, they will be exempt from penalties. Meanwhile, those who do submit data will be scored on the data they submit, but the categories will be reweighted. If you were impacted in 2017, you may submit an application for reweighting of the PI category. Even if you don’t submit a PI application, CMS will automatically exempt you from Quality, Cost and IA for 2017.

8. Small practice bonus instituted

In an effort to further reduce the MIPS reporting burden for small practices, CMS will automatically award qualifying practices a bonus of up to 5 points. Practices must have 15 or fewer ECs and submit data on at least one performance category to be eligible.

9. 2014 CEHRT permitted and 2015 CEHRT bonus created

Originally, CMS planned to allow 2018 MIPS data submission only from 2015 Certified Electronic Health Record Technology (CEHRT). Instead, it has now decided to continue allowing ECs to use 2014 CEHRT—a relief for both vendors and providers. However, CMS is offering a 10% bonus in the PI category to providers who report with 2015 CEHRT.

10. New ePrescribing and HIE exclusions established starting 2017

To allay concerns about the difficulty of meeting certain measures involving ePrescribing and health information exchange (HIE), CMS has introduced new exclusions that would allow ECs to claim the exclusion from one or both of those measures and still earn a base score. It’s important to note that these exclusions are being applied to the 2017 performance year as well as 2018.

Who’s eligible? To claim the eRx exclusion, a provider or group must write fewer than 100 permissible prescriptions during the reporting period. For the HIE exclusion, they must refer or transition fewer than 100 times during the reporting period.


With these new rules, CMS is continuing to ramp up the reporting requirements as planned, building up to full MIPS implementation in 2019. In response to concerns from the healthcare community about the burden of Quality Payment Program reporting, CMS is also focusing heavily on easing the transition and accommodating real clinical workflows.

Especially for small practices, the new Quality Payment Program rules provide additional flexibility and incentives in a wide variety of areas. As a result, some organizations have actually criticized CMS for not challenging providers enough to substantially improve health outcomes or reduce costs. However, for many physicians and industry associations, this relative leniency comes as a major relief.

To learn more and view the full list of calendar year (CY) 2018 MIPS changes, check out CMS’ 2018 Quality Payment Program Final Rule fact sheet.

The Bottom Line

Value-based care is here to stay, but it’s reassuring to see that CMS continues to listen to feedback from the healthcare community. And ultimately, meeting these new MIPS requirements doesn’t have to require an enormous amount of time and resources—it just comes down to whether you have the right tools.

With the performance periods for Quality and Cost beginning on January 1st for all MIPS-eligible clinicians, now is a good time to evaluate whether your current EHR system will be able to support your MIPS success in 2018. A robust MIPS solution should be able to collect reportable MIPS data during the exam, track and benchmark your CPS in real time and submit your data directly to CMS. Plus, consider augmenting your technology with personal guidance from certified MIPS coaches who are also experts in your EHR system. When you’re equipped with comprehensive MIPS support tools from a proven MIPS performer, you can gain peace of mind while helping increase your Medicare income.

We wish you the best of luck with your 2018 MIPS reporting!


Centers for Medicare & Medicaid Services. Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year. Federal Register. https://www.federalregister.gov/documents/2017/11/16/2017-24067/medicare-program-cy-2018-updates-to-the-quality-payment-program-and-quality-payment-program-extreme. Published November 16, 2017. Accessed November 29, 2017.

Centers for Medicare & Medicaid Services. Quality Payment Program Year 2 Final Rule Overview. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Payment-Program/resource-library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf. Accessed November 29, 2017.

CMS’ final rule changes MIPS requirements, fee schedule. American Optometric Association. https://www.aoa.org/news/practice-management/pfs-final-rule-and-2018-mips. Published November 14, 2017. Accessed November 29, 2017.

Dustman R. Virtual Groups: There’s Value in Volume. AAPC. https://www.aapc.com/blog/40154-mips-eligible-clinicians-in-virtual-groups-qualify-for-payment-adjustments/. Published November 14, 2017. Accessed November 29, 2017.

Hagland M, Leventhal R, Landi H, Raths D. Breaking News: CMS Publishes CY 2018 MACRA QPP Final Rule. Healthcare Informatics Magazine. https://www.healthcare-informatics.com/article/payment/breaking-news-cms-publishes-cy-2018-macra-qpp-final-rule. Published November 2, 2017. Accessed November 29, 2017.

Knapple W. CMS Releases Final CY 2018 MIPS & APMs Requirements. American College of Gastroenterology Blog. https://acgblog.org/2017/11/03/cms-releases-final-cy-2018-mips-apms-requirements/. Published November 3, 2017. Accessed November 29, 2017.

MIPS Overview. Quality Payment Program. https://qpp.cms.gov/mips/overview. Accessed November 29, 2017.

Panjamapirom T, Lazerow R. 10 takeaways on the 2018 MACRA final rule. Health Data Management. https://www.healthdatamanagement.com/opinion/10-takeaways-on-the-2018-macra-final-rule. Published November 3, 2017. Accessed November 29, 2017.

Rappleye E. 2018 final rule for MACRA’s Quality Payment Program is here: 10 things to know. Becker’s Hospital Review. https://www.beckershospitalreview.com/finance/2018-final-rule-for-macra-s-quality-payment-program-is-here-10-things-to-know.html. Published November 3, 2017. Accessed November 29, 2017.


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