Frequently Asked Questions

The Centers for Medicare & Medicaid Services (CMS) began implementing sweeping payment reforms called for under the Medicare Access and CHIP Reauthorization Act (MACRA) in 2017. MACRA repealed the sustainable growth rate (SGR) formula and created the Quality Payment Program (QPP) with the intent of rewarding physicians and clinicians for giving better care, not just more care. Clinicians have two tracks to choose from in the Quality Payment Program based on their practice size, specialty, location or patient population: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

The ASA MACRA website only provides information on the previous and current performance year. For more information on previous QPP rules and reporting criteria, visit the official QPP website. 

Physicians and other clinicians should check their MIPS participation status on the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP) website.

Anesthesiologists and other clinicians who bill Medicare Part B must participate and will be subject to a penalty unless they qualify for one of the following exemptions:

1. Clinicians not meeting the Low Volume Threshold. This is defined as clinicians billing less than or equal to $90,000 in allowed charges, seeing less than or equal to 200 Medicare patients and providing fewer than 200 covered professional services under the Physician Fee Schedule.
2. Clinicians participating as a QP in Advanced APMs are exempted from reporting MIPS.
3. Clinicians in their first year of Medicare Part B participation.

Learn more about how MIPS participation is determined on the QPP website.

Eligible clinicians (ECs) or their groups reporting MIPS will receive scores in four MIPS categories: Quality, Cost, Promoting Interoperability and Improvement Activities.

For 2019 and beyond, the performance period for the Quality and Cost components is the 12-month, calendar year. The Improvement Activities and Promoting Interoperability components must be reported for 90 consecutive days during the reporting year.

ECs or their groups may submit MIPS data by using claims (small practices only), Qualified Registry, Qualified Clinical Data Registry, Electronic Health Records and, for certain groups, via CMS Web Interface. ECs and groups may also submit and attest to MIPS components via the QPP website portal.

MIPS eligible clinicians (ECs) can choose to be assessed individually identified by their NPI/tax identification number (TIN) or as a group, defined by their TIN. An EC’s final score may be impacted based on whether he or she reported individually or as a group.

ECs and their practices should check their status on the MIPS Participation Status site to determine if they are eligible to report either as individuals or as a group.

Individual: ECs reporting at the individual level will be assessed based upon their National Provider Identifier (NPI)/Tax Identification Number (TIN) combination. Payment adjustments are based on performance across all MIPS categories and will be applied to the individual EC’s Medicare Part B reimbursements in the correlating payment year. If a clinician does not meet the minimum threshold for MIPS they are exempt from reporting MIPS at the individual level. The low volume threshold for individuals is defined as clinicians with less than or equal to $90,000 in allowed charges, less than or equal to 200 Medicare patients and less than 200 covered professional services under the Physician Fee Schedule. Individuals that meet some, but not all, of these criteria can still choose to opt in to MIPS reporting beginning in 2019.

Group: A practice can report as a group when two or more ECs reassign their billing rights to a single TIN. Groups are assessed collectively at the TIN level across all MIPS categories and payment adjustments will be applied across the group. To participate as a group, the group must report data for all clinicians, including those that would have been exempt as individuals. The low volume threshold for groups is defined as practices with less than or equal to $90,000 in allowed charges, less than or equal to 200 Medicare patients and less than 200 covered professional services under the Physician Fee Schedule. Groups that meet some, but not all, of these criteria can choose to opt in to MIPS reporting. If a practice chooses to report via group, then all clinicians in the group must report. 

There are several special statuses that may alter how an EC or group reports data in the Quality Payment Program. Special statuses are not based upon specialty, but rather the patient populations you and your group deliver care to, the location of your practice and the locations where you and your colleagues work.

In addition to hospital-based and non-patient facing special statuses, ECs may also qualify for an automatic exception for the Promoting Interoperability component under the Ambulatory-Surgery Center-Based ECs. CMS will also provide details on whether you quality as a rural practice or are located in a Health Professional Shortage Area (HPSA).

ECs and their practices can check their special status on the MIPS Participation Status site.

For the Merit-based Incentive Payment System (MIPS), CMS reviews past and current Medicare Part B Claims and PECOS data for clinicians and practices twice for each Performance Year. Each review, or “segment”, looks at a 12-month period. Data from the first segment is released as preliminary eligibility. Data from the second segment is reconciled with the first segment and released as the final eligibility determination.

The first determination period for 2020 participation and special status is October 1, 2018 – September 30, 2019 with notification available in December 2019. The second determination period and special status is October 1, 2019 – September 30, 2020 with notification published in November 2020.

If the EC or group bills Medicare Part B data in both segments, they must exceed the low-volume threshold during both segments to be eligible for MIPS.