MIPS basics for medical practices

The Quality Payment Program, or QPP, was introduced as a framework for Medicare payment reform. Under QPP, eligible clinicians generally participate through one of two primary pathways: MIPS, which is the subject of this guide, or Advanced Alternative Payment Models, known as Advanced APMs. Practices that do not qualify for the Advanced APM pathway and do not receive an exemption may be subject to MIPS in a given performance year.

MIPS brings together several legacy CMS quality reporting programs under a single performance framework. Under MIPS, eligible clinicians submit data across defined performance categories during the performance year. CMS uses this data, along with applicable weighting and scoring rules, to determine a final MIPS score that applies to payment adjustments in a future year.

MIPS eligibility generally depends on clinician type, Medicare enrollment timing, Advanced APM participation status, and whether the clinician or group exceeds the low-volume threshold. For the 2026 performance year, otherwise eligible clinicians are generally required to participate in MIPS when they exceed all 3 low-volume threshold criteria:

• More than $90,000 in Medicare Part B allowed charges for covered professional services
• More than 200 Medicare Part B patients
• More than 200 covered professional services furnished to Medicare Part B patients

Eligibility should always be verified through official QPP/CMS resources because status can vary by TIN/NPI combination, reporting method, and determination period.

Clinicians or groups that meet some, but not all, of the low-volume threshold criteria may have different participation options, such as opt-in or voluntary reporting, depending on their official QPP eligibility status.

Before a practice begins measure planning or data collection, it should confirm whether each applicable clinician is required to participate, eligible to opt in, voluntarily reporting, excluded, or participating through an Advanced APM pathway. This helps the practice avoid building a reporting workflow around the wrong participation status.

MIPS performance is measured across four categories. Each category contributes to the overall MIPS score according to weights established by CMS. These weights and the specific requirements within each category can change from performance year to performance year through annual CMS rulemaking.

• Quality: Clinicians report on a set of clinical quality measures relevant to their specialty and patient population
• Improvement Activities: Practices attest to completing practice improvement activities from a CMS-defined list
• Promoting Interoperability: Clinicians demonstrate use of certified EHR technology and health information exchange
• Cost: CMS calculates cost measures using Medicare claims data, generally without requiring clinician submission

The specific measures available, the weights assigned to each category, and the submission requirements for each category are defined in annual CMS final rules. Practices should review the current-year Final Rule and QPP guidance to understand what applies to their specific situation.

MIPS is structured as a budget-neutral program under the original legislative framework, meaning that payment adjustments can be positive, negative, or neutral depending on overall MIPS performance relative to defined thresholds. Clinicians who participate and score at or above a performance threshold receive no negative adjustment. Those who score above the threshold may receive a positive adjustment. Those who do not participate or score below the threshold may receive a negative adjustment.

Payment adjustments are applied to Medicare Part B payments in the year following the performance year, not in the year the data is collected. The specific adjustment percentages and thresholds are governed by CMS rules and may change. Practices should review official CMS/QPP guidance for current-year adjustment rules rather than relying on general descriptions.

MIPS reporting is a year-long process. Quality measures require data collected across patient encounters throughout the performance year. Improvement Activities must be completed within the performance year. Promoting Interoperability measures depend on EHR configuration and workflow throughout the year. Practices that begin preparation late often find that data gaps, documentation issues, and measure selection decisions cannot be corrected retroactively.

Beginning the MIPS readiness process early, including verifying eligibility, selecting appropriate measures, configuring EHR workflows, and establishing data collection practices, gives practices the best opportunity to build a complete, organized submission. It also allows time to identify and address gaps before they become problems at the end of the performance year.