This content was excerpted from EyeNet’s MIPS 2018; also see the Academy’s MIPS hub page.
Eligible clinicians may participate in MIPS. The term eligible clinician—meaning a clinician who is eligible to take part in MIPS—includes physicians, optometrists, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.
MIPS eligible clinicians must participate in MIPS. Not all eligible clinicians have to participate in MIPS (see the 3 exclusions, described below), but those that do are known as MIPS eligible clinicians. (Note: When the MIPS regulations use the term MIPS eligible clinician, it doesn’t just refer to individuals who are taking part in MIPS, it can also refer to a group that includes such an individual.)
Some eligible clinicians may be exempt from MIPS. You may be exempt from MIPS if at least 1 of the following 3 exclusions applies.
Exclusion 1—Eligible clinicians who are new to Medicare. If you enroll in Medicare for the first time in 2018, and you have not previously submitted claims under Medicare, you will be exempt from the MIPS rules for the 2018 performance year. Furthermore, eligible clinicians who enroll in Medicare toward the end of 2018 may also fall within the low-volume exclusion for the 2019 performance year (see below).
Exclusion 2—Eligible clinicians who are below the low-volume threshold. You will be exempt from MIPS if, over a 12-month period (see next paragraph), you:
- have Medicare Part B allowed charges of no more than $90,000, or
- care for no more than 200 Medicare Part B beneficiaries.
You have 2 chances to qualify for the low-volume exclusion. To see if you are exempt for the 2018 performance year, CMS will review your data for 2 time periods:
- Sept. 1, 2016, to Aug. 31, 2017, with a 30-day claims run out.
- 1, 2017, to Aug. 31, 2018, with a 30-day claims run out.
If you are below the low-volume threshold during either of these time periods, you will be exempt—even if you surpass the threshold in the other time period. Why does CMS check data for 2 time periods? The intent of the earlier time period was to enable CMS to inform MIPS eligible clinicians that they are exempt before the performance year started. The review of more current data will identify practices that have had a drop in volume.
Low-volume threshold determinations are made at the individual level and at the group level. An eligible clinician could fall below the low-volume threshold at the individual reporting level, but he or she would not be exempt from MIPS if reporting as part of a group that exceeds that threshold. Note: Low-volume threshold determinations are not made at the virtual group level.
Exclusion 3—Eligible clinicians in advanced APMs. If you are participating in an advanced APM (see APMs in Brief), you may be exempt from the MIPS rule if you satisfy the APM track’s reporting thresholds.
Does an exclusion apply to you? You should receive a letter from CMS indicating whether you are a MIPS eligible clinician and whether any of the 3 exclusions apply to you. Later this year, CMS will perform a second review of clinicians—reviewing services provided from Sept. 1, 2017, to Aug. 31, 2018 (see “Exclusion 2,” above)—to see if any providers should be added to the low-volume exclusion list.
You also will be able to check online whether a new clinician exclusion or a low-volume exclusion applies to you; you can use a second lookup tool to check whether you are an APM participant. Tip: When you use these lookup tools to check for exclusions, make sure you are checking for the 2018 (not 2017) performance year.
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