The way CMS determines eligibility may change each Performance Year (PY) due to changing policy.
2022 MIPS Eligibility
Your eligibility is based on your:
- National Provider Identifier (NPI) and
- Associated Taxpayer Identification Numbers (TINs).
A TIN can belong to:
- You, if you’re self-employed,
- A practice, or
- An organization like a hospital.
When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination.
If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations.
CMS evaluates each TIN/NPI combination for MIPS eligibility and uses TINs to evaluate practices for eligibility.
Helpful Information
Check your MIPS Participating Status by entering your 10-digit National Provider Identifier (NPI) number to view your QPP participation status by performance year (PY).
MIPS Determination Period
CMS reviews past and current Medicare Part B Claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each Performance Year. Each review, or “segment”, analyzes a 12-month period.
Analysis of data from the first segment is released as preliminary eligibility. Analysis of data from the second segment is reconciled with the first segment and released as the final eligibility determination.
Clinicians and practices generally must exceed the low-volume threshold (LVT) during both segments of the MIPS Determination Period to be eligible for MIPS. Exception: Eligibility will be based solely on segment 2 data when a TIN or TIN/NPI combination is newly established during segment 2 of the MIPS Determination Period.
Learn more about the MIPS determination period
MIPS Low-Volume Threshold
The low-volume threshold includes 3 aspects of covered professional services:
- Allowed charges
- Number of Medicare patients who receive services
- Number of services provided
You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments of the MIPS Determination Period, you:
- Bill more than $90,000 for Part B covered professional services, and
- See more than 200 Part B patients, and;
- Provide more than 200 covered professional services to Part B patients.
If you start billing Medicare Part B claims under a practice’s TIN during segment 2, your eligibility at that practice will be based solely on the results from the analysis of segment 2 data.
MIPS Eligible Clinician Types
You are eligible to report for MIPS if you are a MIPS eligible clinician type (and also meet all the other requirements in the next section). If you’re not one of these clinician types, you’re exempt from reporting.
- Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
- Osteopathic practitioners
- Chiropractors
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Physical therapists
- Occupational therapists
- Clinical psychologists
- Qualified speech-language pathologists
- Qualified audiologists
- Registered dietitians or nutrition professionals
- Clinical social workers
- Certified nurse midwives
MIPS Eligible Clinicians
There are different ways to become a MIPS eligible clinician, depending on whether you’re reporting as an individual, as part of a group, or as part of a virtual group. If you don’t meet the requirements in this section, you’re exempt from MIPS.
Learn more about what to do next as a MIPS eligible clinician
MIPS Eligible as an Individual
In order to be MIPS eligible as an individual clinician, you must:
- Be identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled in Medicare before 2022,
- Not be a Qualifying Alternative Payment Model Participant (QP), and
- Exceed the low-volume threshold as an individual.
If you’re MIPS eligible as an individual, you’re required to report for MIPS.
MIPS Eligible as Part of a Group
In order to be MIPS eligible as part of a group, you must:
- Be identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled in Medicare before 2022,
- Not be a Qualifying Alternative Payment Model Participant (QP), and
- Be associated with a practice that exceeds the low-volume threshold.
If a practice is MIPS eligible, it may report for all clinicians in the practice as a group. In that case, you’ll receive a score and a payment adjustment based on that group’s reporting (unless a higher final score can be attributed to you from individual or APM Entity participation).
In order for a practice to be MIPS eligible, it must:
- Exceed the low-volume threshold and,
- Have at least one clinician who:
- Is identified as a MIPS eligible clinician type on Medicare Part B claims,
- Enrolled as a Medicare provider before 2022, and
- Is not a QP.
MIPS Eligible in a MIPS APM
CMS no longer conducts low-volume threshold determinations at the APM Entity level. The same rules for MIPS eligibility apply to APM participants as to other MIPS eligible clinicians. Clinicians who are both MIPS APM participants and who are MIPS eligible at the individual or group level can report to traditional MIPS and/or report to MIPS via the APM Performance Pathway (APP).
Qualifying APM Participants (QPs) and Partial QPs who elect not to report to MIPS, aren’t required to report to MIPS. You may verify your eligibility in the QPP Participation Status Lookup Tool. MIPS eligible clinicians who participate in a MIPS APM have the option to report to MIPS via the APM Performance Pathway (APP).
MIPS Eligible in a Virtual Group
If you participate in a virtual group, then you may be MIPS eligible in a virtual group. To be eligible in a virtual group you must:
- Be identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled in Medicare before 2022,
- Not be a Qualifying Alternative Payment Model Participant (QP), and
- Participate in a practice that exceeds the low-volume threshold and is part of a virtual group.
If you’re MIPS eligible in a virtual group, the virtual group is required to report your data and you’ll receive a final score and MIPS payment adjustment based on the virtual group’s reporting.
For detailed and up-to-date information please visit the Quality Payment Program website.