Ophthalmology and Optometry Coding Alert

Answer: For 2022 and 2021, the Centers for Medicare & Medicaid Services (CMS) had broad exemptions available due to the COVID-19 pandemic. But if conditions continue to improve, we may not see the same flexibilities available going forward. There are several statuses and exemptions for one or all components of the Merit-based Incentive Payment System (MIPS) program including:

Exclusion 1: New Medicare-Enrolled Physicians

Providers newly enrolled in Medicare for the first time during the performance period aren’t required to participate. This means that if 2021 is your provider’s first year submitting claims to Medicare, you’re in the clear.

Exclusion 2: Low Volume Threshold

MIPS-eligible clinicians do not have to participate in the program if they are otherwise eligible but do not meet the volume threshold for allowable charges, Medicare patients, and billable services. Providers are excluded if they have Medicare allowable charges less than or equal to $90,000; or if they provide care for 200 or fewer Part B-enrolled Medicare patients; or provide 200 or fewer covered professional services.

Exclusion 3: QP Status

The Quality Payment Program (QPP) encourages participation in advanced alternative payment models (APMs). Clinicians determined to be Qualifying APM Participants (QPs) or partial Qualifying APM Participants (Partial QP) are exempt from MIPS.

Which Statuses Change Reporting Requirements?

Under MIPS, CMS automatically assigns special statuses to clinicians, practices, and virtual groups who meet certain criteria. Reporting requirements may change if a special status — small practices, non-patient facing, hospital-based, and ambulatory surgery center (ASC)-based — is achieved.

Not sure if your small practice is eligible for certain program flexibilities? For providers MIPS-eligible at the individual level, the MIPS-eligible clinician will receive small practice status if they are one of 15 or fewer clinicians billing under the practice’s tax identifier number (TIN). If your practice is MIPS-eligible at the group level only, it will receive small practice status if there are 15 or fewer clinicians billing under the practice’s TIN.

If you’re identified as a small practice, you’ll earn two times the points for each improvement activity you submit. If you submit at least one quality measure, you also will receive six bonus points in the quality performance category.

Beginning with the 2022 performance year, you also qualify for automatic reweighting of the Promoting Interoperability performance category to 0 percent. The 25 percent category weight will be redistributed to other performance categories unless you choose to submit Promoting Interoperability data.

Ophthalmologists and optometrists should be aware of their MIPS reporting requirements. To verify whether you will need to submit data for MIPS, use the CMS MIPS participation lookup tool.