This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.
Understand two related terms—eligible clinicians and MIPS eligible clinicians. Under the Quality Payment Program, which includes an advanced alternative payment model (APM) pathway and a MIPS pathway, certain clinicians are classified as eligible clinicians, and a subset of those—those classified as MIPS eligible clinicians—take part in MIPS. If you are an eligible clinician, CMS will count you when it is determining practice size (see “Small or Large Practice?”) regardless of whether or not you are a MIPS eligible clinician.
Who are the eligible clinicians? You are considered an eligible clinician if 1) you have a unique TIN/NPI combination (Tax Identification Number/National Provider Identifier) and 2) you fall within one of these clinician types:
- physician assistants,
- nurse practitioners,
- clinical nurse specialists,
- certified registered nurse anesthetists,
- clinical psychologists,
- physical therapists,
- occupational therapists,
- qualified speech-language pathologists,
- qualified audiologists,
- registered dieticians or nutrition professionals,
- certified nurse midwives, and
- clinical social workers.
Who are the MIPS eligible clinicians? You are considered a MIPS eligible clinician if:
- you are an eligible clinician (see above) and none of the exclusions (see below) apply to you, or
- you are an eligible clinician who decides to "opt in" to MIPS even though you fall below one or two (but not all three) of the low-volume thresholds (see "Exclusion 2," below).
(Note: When the MIPS regulations use the term MIPS eligible clinician, it doesn’t just refer to individuals, it can also refer to a group that includes such an individual.)
Are you exempt from MIPS? You may be exempt from MIPS if at least one of the following three exclusions applies.
Exclusion 1—eligible clinicians who are new to Medicare. If you enroll in Medicare for the first time in 2023, and you have not previously submitted claims under Medicare, you will be exempt from the MIPS rules for the 2023 performance year.
Exclusion 2—eligible clinicians who are below the low-volume threshold. You will be exempt from MIPS if, during either of two 12-month segments (see “MIPS Determination Period”), you:
- have allowed charges for covered Medicare Part B professional services of $90,000 or less; or
- provide covered professional services to no more than 200 Medicare Part B beneficiaries; or
- provide 200 or fewer covered professional services to Part B beneficiaries. (Note: If you see one beneficiary one time, that counts as one service; if you see a second patient five times, that would count as another five services.)
The difference between the second and third low-volume criteria can become significant when determining which low-volume clinicians can opt-in to MIPS.
Two chances to meet the requirements of the low-volume exclusions. The fact that the MIPS determination period is comprised of two time segments means that you have two chances to qualify for a low-volume exclusion: If you fall below the low-volume threshold for one time segment, you will be eligible for an exclusion—even if you exceed the threshold in the other time segment. Note: Low-volume clinicians can opt in to MIPS.
Low-volume threshold determinations are made at the individual level and at the group level. A MIPS eligible clinician could fall below the low-volume threshold at the individual-reporting level but would not be exempt from MIPS if reporting as part of a group that exceeds that threshold at the group level.
Exclusion 3—eligible clinicians who are qualifying participants (QPs) in advanced APMs. If you are participating in an advanced APM, you may be exempt from the MIPS rule if you satisfy the APM track’s thresholds.
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