The rules and requirements have changed each year of the MIPS program. Here is a list of the major modifications from previous years. More information about these topics can be founded in the referenced section:

• Increased performance threshold - 75 points
• Increased exeptional performance threshold - 89 points
• Decreased Quality performance category weight - 30 points
• Increased Cost performance category weight - 30 points

Physicians can look up eligibility on the QPP Participation Lookup tool based on their National Provider Identification (NPI) number.

You’re considered a MIPS eligible clinician (i.e. required to report) and will receive a payment adjustment when:
• You’re an eligible clinician type AND
• You enrolled in Medicare before January 1, 2022 AND
• You’re not identified as a QP AND
• You exceed the low-volume threshold

To exceed the low-volume threshold for the 2022 performance year, you must:
• Bill more than $90,000 for Part B covered professional services under the Physician Fee Schedule (PFS), AND
• Provide services to more than 200 Medicare Part B patients, AND
• Furnish more than 200 covered professional services to Part B Medicare Patients.

These requirements allow for physicians to opt-in to MIPS if they meet at least 1 of the 3 criteria. Those opting in will receive the related payment adjustment 2 years later. Those that do NOT meet any of the criteria can voluntarily report data; however, they will not receive a payment adjustment.

Eligible clinicians include:

• Clinical social workers (new)
• Certified nurse-midwives (new)
• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Registered dietician or nutrition professional
• Physical therapists
• Occupational therapists
• Qualified speech-language pathologists
• Qualified audiologists
• Clinical psychologists

There are many requirements and rules in MIPS, however there is still a large amount of flexibility for participating in the program.

Traditional MIPS
What has historically been referred to as MIPS is now called Traditional MIPS. Under the traditional MIPS, participants select from 200 quality measures and over 100 improvement activities, in addition to reporting the complete Promoting Interoperability measure set. CMS collects and calculates data for the Cost performance category for you, if applicable.

In addition to traditional MIPS, 2 other MIPS reporting frameworks, designed to reduce reporting burden, will be available to MIPS eligible clinicians.

The APM Performance Pathway (APP), is a streamlined reporting framework available beginning with the 2021 performance year for MIPS eligible clinicians who participate in a MIPS APM. The APP is designed to reduce reporting burden, create new scoring opportunities for participants in MIPS APMs, and encourage participation in APMs.

MIPS Value Pathways (MVPs) are subsets of measures and activities, established through rulemaking, that can be used to meet MIPS reporting requirements beginning with the 2023 performance year. The MVP framework aims to align and connect measures and activities across the Quality, Cost, and Improvement Activities performance categories of MIPS for different specialties or conditions. In addition, MVPs incorporate a foundational layer that leverages Promoting Interoperability measures and a set of administrative claims-based quality measures that focus on population health/public health priorities. There are 7 MVPs that will be available for reporting in the 2023 performance year, none of which are oncology focused.

MIPS provides several data submission options, and most are available for Quality, Improvement Activities and the Promoting Interoperability performance categories. Data can be submitted via multiple mechanisms within a performance category. For example, a physician can utilize a registry to report some quality measures and claims to report others. If the same measure is submitted via multiple mechanisms, the one with the greatest number of measure achievement points will be selected for scoring.

Only small practices (≤15 eligible clinicians) can use Claims for data submission. It’s not an option if you’re participating in MIPS as a large group. Claims data is only available for the Quality performance category. If you choose to submit quality data through claims, Quality Data Codes (QDCs) will need to be added to denominator eligible claims to show that the required quality action occurred, or exclusion applied. QDCs are specified Current Procedure Terminology (CPT) II codes (with or without modifiers) and G-codes used for submission of quality data for MIPS. When these codes are included on your claims form, it identifies your selected quality measures for CMS. You’ll also need to apply encounter codes, including ICD-10-CM, CPT Category I, or Healthcare Common Procedure Coding System (HCPCS) codes. These codes show which patients should be added toward the denominator/numerator of the quality measure.

A Registry is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. Each registry is different; however, most will collect data for the Quality, Improvement Activities and Promoting Interoperability performance categories. A full list of CMS-approved entities can be found on the CMS website.

A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity that collects clinical data from an individual MIPS-eligible clinician, group, and/or virtual group and submits the data to CMS on their behalf. The QCDR reporting option is different from a Registry because it is not limited to quality measures within MIPS. The QCDR can develop and submit QCDR measures for CMS consideration and approval.

An Electronic Health Record (EHR) can provide two ways to submit data to CMS. Either the vendor can submit MIPS data to CMS on your behalf or the vendor can provide the clinician with a Quality Reporting Document Architecture III (QRDA3) file which you can submit on your own through the CMS Portal. If a practice transitions from one EHR system to another EHR system during the performance year, the practice should aggregate the data from the previous EHR system and the new EHR system into one report for the full 12 months prior to submitting the data. If a full 12 months of data is unavailable (for example if aggregation isn’t possible), the data completeness must reflect the 12-month period. If a clinician is submitting eCQMs, both EHR systems must meet the 2015 Edition CEHRT criteria, the 2015 Edition Cures Update criteria, or a combination of both.

The CMS Portal is a secure internet-based data submission mechanism available for all physicians and groups. To sign into the CMS portal, you will need your HCQIS Access Roles and Profile (HARP) system credentials and have the appropriate user role associated with your organization. Password reminders and registration for new users can be found on the QPP webpage. You will be able to report as either a group or individual for each TIN associated with the account. Attestation is available for the Improvement Activities and Promoting Interoperability performance categories. For the Quality performance category, users will be able to import an approved data file.

If you choose to submit a specialty measure set, you must submit data on at least 6 measures within that set. If the set contains fewer than 6 measures, you should submit each measure in the set. The Radiation Oncology Specialty Measure Set only includes three measures.

There are 6 collection types for MIPS quality measures:

• Electronic Clinical Quality Measures (eCQMs)
• MIPS Clinical Quality Measures (CQMs)
• Qualified Clinical Data Registry (QCDR) Measures
• Medicare Part B claims measures
• CMS Web Interface measures
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey.

CMS determines measure achievement points by comparing performance on a measure to a measure benchmark.

If a measure can be reliably scored against a benchmark, it generally means:

• A benchmark is available.
• Has at least 20 cases.
• It meets the data completeness requirement standard, which is generally 70%.

Bonus Points 
As finalized in the CY 2022 Physician Fee Schedule Final Rule, CMS removed bonus points for end-to-end electronic reporting and reporting additional outcome/high priority measures. This will allow for a shift towards a more simplified scoring standard focused on measure achievement.

Six bonus points will still be added to the Quality Performance Category score for clinicians in small practices who submit at least 1 measure, either individually or as a group or virtual group. This bonus isn’t added to clinicians or groups who are scored under facility-based scoring.

Clinicians may also earn up to 10 additional percentage points based on the improvement in the Quality Performance Category from the previous year.

Facility-Based Scoring
Beginning in 2019, clinicians that furnish 75 percent or more of their covered professional services in POS 21, 22 or 23, and have at least a single service billed with POS 21 (inpatient hospital) or 23 (emergency room) can use the Quality and Cost scores with the facility’s Value-Based Purchasing score. Practices will still need to report on the Improvement Activities and Promoting Interoperability category separately.

Administrative Claims
CMS will automatically calculate and score individuals, groups, and virtual groups on 3 administrative claims measures when the individual, group, or virtual group meets the case minimum and clinician requirement for the measures.

• Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups. (This measure is available for groups and virtual groups only).
• Risk-standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS).
• NEW: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions.

Clinicians may submit a MIPS Promoting Interoperability Performance Category Hardship Exception Application, citing one of the following reasons for review and approval:

• MIPS eligible clinician using decertified EHR technology
• Insufficient internet connectivity
• Extreme and uncontrollable circumstances
• Lack of control over the availability of CEHRT

If the hardship exception is approved, the Promoting Interoperability Performance Category will receive a weight of 0% when calculating the final score and the 25% will be redistributed to another performance category (or categories).

Some clinicians will be automatically reweighted based on:

• Special status (for example, hospital-based clinicians),
• Clinician type (for example, a physical therapist, occupational therapist, or clinical psychologist, or clinical social worker), or;
• Small practice.

These clinicians will not need to submit a Promoting Interoperability hardship exception application.

If clinicians are reporting as a group or virtual group all MIPS eligible clinicians in the group or virtual group must qualify for reweighting for the group to be reweighted, unless the group or virtual group has a special status that qualifies them for automatic reweighting.

FoFor Performance Year 2022, clinicians are required to use an Electronic Health Record (EHR) that meets the 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of both for participation in this performance category.

Clinicians must submit collected data for certain measures from each of the 4 objectives measures (unless an exclusion is claimed) for the same 90 continuous days (or more) during 2022.

In addition to submitting measures, clinicians must provide the EHR’s CMS Identification code from the Certified Health IT Product List (CHPL) and submit a “yes” to:

• The Prevention of Information Blocking Attestation,
• The ONC Direct Review Attestation,
• The security risk analysis measure, and;
• The SAFER Guides measure.

There are over one hundred activities to choose from in 2022. How activities are weighted is an important factor in determining the score and how best to satisfy the minimum requirements. For a full list of the activities, visit CMS’s QPP website.

In 2022 groups can attest to an improvement activity when at least 50% of the clinicians perform the same activity during any continuous 90-day period within the same performance year.

While only attestation of activity completion is necessary for reporting, practices should maintain documentation to demonstrate consistent and meaningful engagement within the performance period. In the event of an audit, documentation must be presented.

RO-ILS: Radiation Oncology Incident Learning System^®, sponsored by ASTRO and AAPM, is a part of Clarity PSO, a federally listed patient safety organization. A medium weighted activity within the “Improvement Activity” (IA) Performance Category is “Participation in an AHRQ-listed patient safety organization." There is no fee to participate in RO-ILS, but the facility must sign an agreement with Clarity PSO so start the contracting process now. Join the more than 800 facilities enrolled in RO-ILS.

For this activity, CMS suggests “documentation from an AHRQ-listed patient safety organization (PSO) confirming the eligible clinician or group's participation with the PSO.” Therefore, upon request, Clarity PSO will send a Letter of Participation stating that your practice or facility is actively participating in RO-ILS during the reporting period. Please email radoncsupport@claritygrp.com to request a RO-ILS Letter of Participation. Letters will be sent later in the year.

Additionally, you can use RO-ILS towards fulfilling the Part IV Physician Quality Improvement (PQI) Maintenance of Certification (MOC) requirements established by the American Board of Radiology. This meets an additional medium-weighted improvement activity (Activity ID = IA_PSPA_2).

ASTRO’s APEx - Accreditation Program for Excellence focuses on a culture of quality and safety, as well as patient-centered care. Evidence Indicators required for APEx Accreditation map to 15 improvement activities. One of these activities is participation in MOC Part IV, which can be accomplished with the APEx PQI template. The APEx Self-Assessment portion of the program can satisfy all the requirements for the Improvement Activities Performance Category.

Activities are either medium-weighted (worth 10 points) or high-weighted (worth 20 points) — most activities are listed as medium-weighted. Clinicians can report any combination of medium and high-weighted activities to meet the necessary points for full credit.

Clinicians will receive double points for each high- or medium-weighted activity submitted if they are an individual clinician, group, virtual group, or APM Entity who holds a qualifying special status. Clinicians can check for any special status by signing in to qpp.cms.gov. Small status designation for APM Entities will be displayed in mid-2022.

The Medicare Spending per Beneficiary cost measure, now called MSPB Clinician (MSPB). The re-evaluated MSPB-C measure assessed the cost performance of clinicians who furnish inpatient care services to Medicare beneficiaries.  The measure includes Medicare Part A and B costs occurring during the episode window, removing certain services identified as unlikely to be influenced by the clinician's care decisions. Medical episodes are attributed to clinician groups that render at least 30 percent of E&M services during the period between the index admission date and the discharge date for a hospitalization with a medical MS-DRG, and to any clinician that billed at least one E&M service under a clinician group that meets the 30 percent threshold.

Episodes will be attributed to the clinician who provided the Part A and Part B services to a beneficiary during the admission.

• Clinicians who do not see patients in the hospital will not be attributed to any episodes and not scored on the measure
• Clinicians must be attributed to at least 35 cases to be scored on the measure

Based on CMS’ calculations for this measure, we believe it could be likely that large radiation oncology practices, submitted as a group, could have the necessary patient counts for this measure in 2022.

The Total per capita cost measure evaluates the overall cost of care provided to beneficiaries attributed to clinicians, as identified by a unique Taxpayer Identification Number/National Provider Identifier (TIN-NPI). The Total Per Capita Costs for All Attributed Beneficiaries measure can be reported at the TIN or the TIN-NPI level.

The measure was re-specified in 2020 to remove clinicians who frequently perform non-primary care services, including radiation therapy, chemotherapy and surgery.  However, other clinicians, such as Nurse Practitioners can still be attributed beneficiaries.

• The beneficiary is attributed to the primary care physician (PCP) who provided the most primary care services during the performance period.
• If a PCP did not bill any primary care services for a beneficiary, then the beneficiary is attributed to the specialist who provided the most primary care services during the performance period
• Clinicians must be attributed to at least 20 unique beneficiaries to be scored on this measure.

Clinicians will be evaluated and scored on each cost measure for which they meet or exceed the established case minimum. Clinicians must meet the established case minimum for and be scored on at least one measure to receive a cost performance category score.

CMS determines measure achievement points by comparing performance on a measure to a performance period benchmark. CMS calculates cost measure benchmarks using performance data from the performance period, rather than historical data.

Facility-Based Scoring
Beginning in 2019, clinicians that furnish 75 percent or more of their covered professional services in POS 21, 22 or 23, and have at least a single service billed with POS 21 (inpatient hospital) or 23 (emergency room) can use the Quality and Cost scores with the facility’s Value-Based Purchasing score. Practices will still need to report on the Improvement Activities and Promoting Interoperability category separately.