The Final Word on How to Determine MIPS Eligibility

The Final Word on How to Determine MIPS Eligibility

With less than three months before the start of the Merit-based Incentive Payment System (MIPS) 2017 performance period, there’s no time to waste in readying your practice to meet the reporting requirements — assuming that you are a MIPS eligible clinician. The Centers for Medicare & Medicaid Services (CMS) made a small and easily overlooked change for determining eligibility in its final rule.
You are a MIPS eligible clinician in years 1 and 2 of the new Quality Payment Program if you:

  • Are a physician, physician’s assistant, nurse practitioner, clinical nurse anesthetist, or a group that includes such clinicians;
  • Received $30,000 or more in Medicare Part B reimbursement and served 100 or more Medicare beneficiaries between September 1, 2015 and August 31, 2016; and
  • Enrolled in Medicare prior to 2017.

You are exempt from MIPS in 2019 if you:

  • Enrolled in Medicare in 2017;
  • Received less than $30,000 in Medicare reimbursement or served less than 100 Medicare beneficiaries between September 1, 2015 and August 31, 2016; or
  • Are a Qualifying APM Participant (QPs have at least 25 percent of their Medicare Part B covered professional services or at least 20 percent of their Medicare beneficiaries furnished Part B covered professional services through an Advanced Alternate Payment Model.)

For example, if you are a physician who enrolled in Medicare in January 2016, and subsequently furnished Medicare-covered professional services to 150 Medicare beneficiaries, for which you were reimbursed $30,000, you are exempt from the 2017 MIPS performance period because of your newly-enrolled status.
In the proposed rule, CMS indicated the eligibility threshold would be $30,000 in billed Medicare Part B allowed charges and 100 or fewer Part B-enrolled Medicare beneficiaries. After considering public comments, CMS changed the “and” to “or” in the final rule to determine ineligibility, only.

2020 and Beyond

For the second year of MIPS, eligibility will be based on 12 months of data starting from September 1, 2016 to August 31, 2017. Similarly, to determine the low-volume status of individual MIPS eligible clinicians and groups for future years, eligibility will be based on 12 months of data (consisting of the last four months of the calendar year, two years prior to the performance period, and the first eight months of the calendar year prior to the performance period).

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

2 Responses to “The Final Word on How to Determine MIPS Eligibility”

  1. Chris Higdon says:

    Do you know if the rules have changed for Federally Qualified Health Clinics (FQHCs)? The last I understood, FQHCs were exempt from MIPs.

  2. Renee Dustman says:

    The final rule says, “After consideration of the public comments we received, we are finalizing our proposal that services rendered by an eligible clinician under the RHC or FQHC methodology, will not be subject to the MIPS payments adjustments. However, these eligible clinicians have the option to voluntarily report on applicable measures and activities for MIPS, in which the data received will not be used to assess their performance for the purpose of the MIPS payment adjustment.”