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Part B Insider (Multispecialty) Coding Alert

Quality Payment Program:

Determine MIPS Eligibility With This 2020 Primer

Hint: Find out if your stats point toward MIPS exemption.

Even though the Quality Payment Program (QPP) is now in its fourth year, that doesn’t make it any less confusing. In fact, due to Medicare’s annual tweaks and turnarounds, many Part B providers still struggle to figure out where they stand in the program.

If you’re bamboozled by Performance Year (PY) 2020 changes or just want to determine if you meet the thresholds, read on for the lowdown on how the Centers for Medicare & Medicaid Services (CMS) calculates Merit-Based Incentive Payment Program (MIPS) 2020 participation and eligibility.

Understand the Nuances of Clinician Types

For PY 2020, the QPP outlines specific MIPS-eligible clinician (EC) types. They include the following, according to QPP guidance:

  • 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

Important: If your specialty is not on this list, you are automatically exempt from MIPS reporting for 2020 — but that doesn’t mean you’ll be exempt in 2021. The QPP final rule usually offers a MIPS EC update, and new clinician types have been added in years past.

Reminder: The basis for your MIPS eligibility is initially determined through your National Provider Identifier (NPI) and associated Taxpayer Identification Numbers (TINs).

See Low-Volume Threshold Details

If you find the low-volume threshold (LVT) numbers confounding, you’re not alone. CMS altered the LVT numbers for PY 2018 and 2019, causing mass confusion. But luckily, CMS kept the same thresholds from last year for PY 2020. This may be due to Part B claims reviews in Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) that spanned two PY segments that had different LVT requirements and caused some MIPS ECs to be in during one segment then out in the next.

For PY 2020, three areas of “covered professional services” fall into the LVT decision making: allowed charges; the number of Medicare Part B beneficiaries who receive care; and the number of services you provide.

Your Part B claims must show the following three low-volume threshold requirements:

1. Bill $90k in Part B allowed charges.

2. Administer care to at least 200 Part B beneficiaries.

3. Provide at least 200 covered fee-schedule services to Part B patients.

Tip: Remember that there are several different reporting options once you’ve figured out if your specialty is on the list, and you meet the LVTs. For example, you can report MIPS measures as an individual, in a group, or in a virtual group.

MIPS APM: If you are on an alternative payment model (APM) participation list but don’t necessarily meet the requirements to be a qualifying APM participants (QP) or are a partial QP, you may be able to submit measures and receive your incentive through a MIPS APM. “To be considered part of the APM Entity for the APM scoring standard, you must be on an APM participation list on at least one of the three snapshot dates of the performance period,” the QPP says. “Otherwise, you must report to MIPS under the standard MIPS methods.”

Opt-in: The PY 2019 QPP final rule confirmed the MIPS “opt-in” eligibility. Now, “clinicians, practices, and APM entities can opt-in to report if they exceed 1 or 2 (but not all 3) of the low-volume threshold criteria as long as they aren’t otherwise exempt. This participation option requires a formal election,” notes QPP guidance.

You can always check your baseline MIPS status with the QPP participation tool at

Know These MIPS Determination Dates and Facts

If you’re wondering how CMS decides whether you’re in or out of MIPS, it all comes down to periodic check-ups of your Part B claims in PECOS — and whether you meet certain LVT requirements during those reviews.

For MIPS eligibility, “we review past and current Medicare Part B claims and PECOS data for clinicians and practices twice for each Performance Year [PY],” explains QPP in its PY 2020 guidance. “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.”

Timeline: Though your basic MIPS status can change for a variety of reasons, including reviews of your PECOS data and Part B claims, you should still be aware of these dates. Medicare already has the first segment — activity from Oct. 1, 2018 to Sept. 30, 2019 — which determined your initial PY 2020 MIPS eligibility, the QPP indicates. This data was released on the QPP site in December 2019.

The second segment determination period runs from Oct. 1, 2019 to Nov. 2020. After the two segments are reconciled, the QPP releases the information and alerts providers on their MIPS eligibility.

And remember, your Part B data must meet LVTs in both segment periods to retain MIPS eligibility. If you are under the LVT during segment 1 or 2 or don’t meet expectations in both, you’re exempt from MIPS, cautions QPP guidance.

Resource: Check past performance years’ determination details and review more 2020 MIPS information at