What Is MIPS in Ophthalmology and How Can You Make the Most of Value-Based Care?

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Review MIPS Measures for Ophthalmology and See How EHRs Can Help with the MIPS Process

New to MIPS or wondering where to start? Let’s begin by going back to where it all started — with the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA, which ushered in the Quality Payment Program (QPP). QPP was created to promote quality care and value in healthcare — two things patients and ophthalmologists both want. At the moment, there are two ways to participate in QPP — through the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models. Since many ophthalmology practices participate in MIPS, this blog will focus on that.

MIPS Eligibility

Did you know that you may be able to participate in MIPS and report on your ophthalmology MIPS measures individually, as part of a group, or both?

Your eligibility status is determined by a number of factors, such as:

  • Clinician type
  • Date of Medicare enrollment
  • The amount of covered professional services you provide to Medicare patients

Want to know if you’re eligible? Grab your 10-digit National Provider Identifier (NPI) number and check your status at the CMS website.

Beginning with the 2023 performance year, CMS has proposed a new framework for participating in MIPS called MIPS Value Pathways or MVPs. ModMed®’s value-based care team has been monitoring all of the latest developments with this program. MVPs were developed to reduce much of the reporting burden and reporting complexity that surrounds MIPS, which is something busy ophthalmology practices are sure to appreciate. The transition period for this program will begin in 2023 and will continue until 2027. MVPs will be mandatory starting in 2028. Interested in participating? You can register in advance here. However, it is likely that ophthalmology practices will need to wait until 2024 or later to participate in this program — there are only seven MVP topics available in 2023.

MIPS Measures for Ophthalmology

MIPS is all about the categories. Quality. Promoting Interoperability. Improvement. Cost. All of these categories count toward your final MIPS score. Each one has different weights, relative to each other, as well as different measures and requirements. Below is a quick overview of these categories. However, keep in mind that the percentages below are from the 2021 performance year (except where noted) and these percentages often vary from year to year.

Quality — 40% of Final Score (This Decreases to 30% in 2022)

  • This category measures healthcare processes, outcomes and the patient experience.
  • To report to this measure you’ll need to submit data for at least six quality measures including one outcome measure (if you don’t have an outcome measure to report, a high-priority measure will suffice) OR a complete specialty measure set.
  • You’ll also need to submit data for at least 70% of your patients who qualify for each measure.
  • Don’t worry: you can submit measures from different collection types to reach a minimum of six quality measures.
  • And remember there are many ophthalmology quality measures you can submit to!

Promoting Interoperability – 25% of Final Score (This Stays the Same in 2022)

  • For performance year 2021, you’re required to use an EHR system that meets the 2015 Edition certification criteria OR the 2015 Edition Cures Update certification criteria OR a combination of both to report to this category.
  • You’ll need to submit data for certain measures from each of the four objective measures for the same 90 continuous days (or more) during 2021.
  • Can’t fulfill the requirements in this category? You may be eligible to submit a MIPS Promoting Inoperability Performance Category Hardship Exception Application.
  • Remember: the Query of Prescription Drug Monitoring (PDMP) is worth 10 bonus points!

Improvement Activities — 15% of Final Score (This Stays the Same in 2022)

  • To meet requirements you need to attest to one of the following:
    • Two high-weighted activities
    • One high-weighted activity and two medium-weighted activities
    • Four medium-weighted activities
  • High-weighted activities receive 20 points and medium-weighted activities receive 10 points
  • Do you hold a special qualifying status? You’ll receive double points for each high- or medium-weighted activity you submit.

What are medium- and high-weighted improvement activities?

CMS defines high-weighted activities as those that closely align with public health priorities. Medium-weighted activities, while important, are not as closely aligned with public health priorities in CMS’s eyes and are weighted half as much as high-weighted activities (10 points instead of 20).

What is a qualifying special status?

This is “an automatically applied determination by CMS that qualifies clinicians, practices, or virtual groups for reduced reporting requirements in certain performance categories,” according to the CMS. You can learn more about special statuses here.

Cost Activities — 20% of Final Score (This Increases to 30% in 2022)

  • Cost is an important part of MIPS because it measures Medicare payments made for care provided to patients.
  • You don’t need to submit any data for this category because CMS uses Medicare Part A and B claims data to calculate your score for you.
  • The 20% weighted score for 2021 could change based on exemptions granted or if you don’t meet established case or patient minimums for the 20 available measures.

MIPS Performance Thresholds and Payment Adjustments

In traditional MIPS for ophthalmology, CMS sets performance thresholds. For example, in the 2021 performance year, you needed to have a final MIPS score of 60 points or more to avoid a negative payment adjustment (or penalty). For the 2022 performance year, this performance threshold increases to 75 points. To be eligible for an exceptional performance bonus for 2021, you need to have a final MIPS score of 85 points or more—this increases to 89 points or more in 2022.


If a bonus or penalty (a positive or negative payment adjustment) is received, those are applied to future Medicare reimbursements two calendar years later. For example, any payment adjustment received during the 2022 performance year, will be applied to Medicare reimbursements beginning on January 1, 2024.

How much are these positive or negative payment adjustments as they are called? For the 2021 and 2022 performance years, it is up to a 9% adjustment (positive or negative) on all Medicare-submitted claims. During the COVID-19 emergency, however, CMS has applied an automatic extreme and uncontrollable circumstances policy to all MIPS-eligible clinicians who are eligible to participate individually.

And now…this…

If you’re lucky enough to reach that high-performance threshold for the 2021 or 2022 performance years, savor the moment. Exceptional performance bonuses are going away after the 2022 performance year.

And in 2023, MIPS is going to begin transforming into MIPS MVPs (starting with voluntary registration) — a new program that seeks to make the reporting process a little easier for everyone.

How EHRs Make MIPS Reporting Easier for Ophthalmologists

EHR systems make MIPS data collection and reporting less of a manual process, helping to take the burden off of your clinical and administrative staff. Here are some of the MIPS-related features you should look for from an EHR vendor:

  • MIPS Dashboard — Want to see how you’re tracking toward your MIPS goals? Check your dashboard, which shows how you’re performing in many MIPS categories.
  • Automated Ophthalmology MIPS Measure Collection — As clinicians enter information into your EHR, your EHR is automatically collecting the measures you need to report to CMS.
  • Ophthalmology-Specific Quality Measures — Our EHR, EMA, gives you the ability to report to most of your specialty-specific quality measures, such as:
    • Age-Related Macular Degeneration (AMD): Dilated Macular Examination
    • Cataract Surgery: Difference Between Planned and Final Refraction
    • Diabetes: Eye Exam
    • Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
    • Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
    • Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
  • MIPS Qualified Registry — An EHR vendor that has its own qualified registry, as ModMed does, makes submission simple.
  • Specialized RegistriesEMA has its own specialized registries for:
    • Dry Eye
    • Primary Open Angle Glaucoma
    • EMA also supports reporting to the IRIS registry.
  • Modern Features — It’s no secret that CMS gives you points for the activities you do to modernize your practice. And the more modern your system is, the more points you stand to gain.

This blog is intended for informational purposes only and does not constitute legal or medical advice. Please consult with your legal counsel and other qualified advisors to ensure compliance with applicable laws, regulations, and standards.

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