This content was excerpted from EyeNet’s MIPS 2019; 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 APM pathway and a MIPS pathway, certain clinicians are classified as eligible clinicians, and a subset of 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 regardless of whether or not you are a MIPS eligible clinician (see Small or Large Practice?).
Who are the MIPS eligible clinicians? For the 2019 performance year, CMS has expanded the definition of MIPS eligible clinician, adding several clinician types. You are considered a MIPS eligible clinician if you fall within one of the following clinician types and either 1) none of the MIPS exclusions (see below) apply to you or 2) one or two of the exclusions apply, but you decide to "opt in" to MIPS:
- physicians,
- optometrists,
- physician assistants,
- nurse practitioners,
- clinical nurse specialists,
- certified registered nurse anesthetists,
- new: clinical psychologists
- new: physical therapists,
- new: occupational therapists,
- new: qualified speech-language pathologists,
- new: qualified audiologists, and
- new: registered dietician or nutrition professional.
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.
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 2019, and you have not previously submitted claims under Medicare, you will be exempt from the MIPS rules for the 2019 performance year.
Exclusion 2—eligible clinicians who are below the low-volume threshold. You will be exempt from MIPS if, over either of two 12-month periods (see "You have two chances to qualify for the low-volume exclusion," below), 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 (this threshold didn’t exist in 2018).
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. In other words, if you exceed the 200 beneficiary–threshold, you also will exceed the 200 professional services–threshold. So why the new threshold? CMS added it to allow more low volume–excluded clinicians to "opt in" to MIPS reporting.
You have two chances to qualify for the low-volume exclusion. To see if you are exempt for the 2019 performance year, CMS will review your data for two time segments, collectively known as the MIPS determination period:
- 1, 2017–Sept. 30, 2018 (with a 30-day claims run out)
- 1, 2018–Sept. 30, 2019 (no claims run out)
If you fall below the low-volume threshold during the first time period, you will be exempt—even if you surpass the threshold in the second time period.
Check your quarterly snapshots. During the determination period’s second time segment (Oct. 1, 2018 –Sept. 30, 2019), CMS has said that it will provide you with quarterly snapshots that would show—based on the data available at that point in time—what the agency’s provisional status and eligibility determinations would be for you (see "Check your status," below). Although the final determinations won’t be made until after Sept. 30, 2019, these informational snapshots will give you a sense of what those final decisions are likely to be.
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 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.
Check your status. You can check online whether low-volume exclusion applies to you. Make sure you have your 10-digit National Provider Identifier (NPI) handy and visit the QPP Participation Status lookup tool. Note: As mentioned above (see “Exclusion 2” ), CMS will perform a second review of clinicians later this year—reviewing services provided from Oct. 1, 2018–Sept. 30, 2019 —to see if any providers should be added to the low-volume exclusion list.
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