Who is required to report MIPS?

All eligible clinicians are required to report MIPS data. Eligibility status is based on two things, NPI and associated TIN. There are many factors that come into play but they are all associated with and TIN/NPI combination. A TIN can belong to a self employed individual, a practice, or an organization, such as a hospital. Since an individual NPI may reassign their Medicare billing rights to multiple TINs, the TIN/NPI combination will be evaluated for eligibility status. In some cases a clinician may be eligible to report MIPS data for one combination but not for another. Practice eligibility is based on a TiN.

What data is used to determine eligibility?

There is a determination period for eligibility using past and current Medicare Part B claims and PECOS data for clinicians and practices. Data is gathered and reviewed twice for each performance year and each analysis and the review is for a 12 month period. Preliminary eligibility is released after the first segment of data is analyzed, but final eligibility is not determined until the first segment data has been reconciled with the second segment data. There is one exception: If a TIN or TIN/NPI combination is newly established during the second segment of the MIPS determination period, then MIPS eligibility will be based only on the segment 2 data.

For clinicians and practices to be MIPS eligible and required to report MIPS, they must:

• be an eligible clinician type on Medicare Part B claims AND
• be enrolled in Medicare before January 1, 2023 AND
• not identified as a Qualifying APM Participant (QP) AND
• exceed the low-volume threshold as an individual

Who is Not required to report MIPS?

If the low volume threshold is not met, the clinician or practice is NOT required to report MIPS data, even though they meet all three of the other requirements. It is also worth noting, that for 2023, if a clinician or practice is granted a hardship exception for 2023, they are also not required to report data for that year. To check EUC hardship status click here.

What are the conditions to meet the Low Volume Threshold?

Allowed charges: Must bill LESS than $90,00 in Medicare Part B covered services AND Provide services to LESS than 200 Medicare Part B patients, AND Provide LESS than 200 services to Medicare Part B patients.

All conditions must be met.

Which provider data is included to determine eligibility?

If the practice chooses to report as a Group, ALL clinicians’ data is included for submission under the TIN, for all performance categories requiring data submission, to determine the Group’s final score. This includes data for clinicians that may not be eligible as individuals. All MIPS eligible clinicians will receive the group’s final score. Any Individually eligible clinicians will also receive the group’s final score unless they have a higher final score from individual or APM participation.

Why is it important to know if an individual or practice is required to report MIPS in 2023?

The answer is simple, it will affect the bottom line. All eligible TIN/NPIs will receive a positive, negative, or neutral MIPS payment adjustment in 2025 based on the data they do or do not submit in 2023. This adjustment will follow the NPI to any new/different practice they may join.

How do I find out if I’m required to participate in MIPS?

You can check your status Here.