MIPS – What’s New, What Isn’t, and What You Need to Know Now
Tuesday, February 5th, 2019

The MIPS program continues, with all of its trials and triumphs. While many of the parts of the program remain the same, there are some key pieces to keep in mind, so you won’t be left behind in the pursuit of a positive attestation. If you haven’t started on MIPS for 2018, there is still a possibility for reporting and meeting the minimum threshold for the reporting year, especially if you have less than 15 clinicians. It is also important to remember if you haven’t actively engaged in MIPS program and are always waiting to hit that neutral adjustment, scores are publicly available on the Physician Compare website for all to see.

The official attestation period for the 2018 reporting year began on January 2, 2019, and the deadline to send everything in is April 2, 2019. For groups submitting their practitioners as individuals (vs. group), consent does have to be given. A Practice Administrator may give consent on behalf of a group or virtual group, but not for a MIPS-eligible clinician reporting as an individual. MIPS data needs to include all payers for QCDR/Registry/EHR submissions. Medicare only applies exclusively to the Claims and Web interface submissions. The completeness of data must include all payers. For group submissions, data across the entire TIN, including data from non-Eligible Clinicians, must be included.

For 2018 the threshold for data completeness is 60%. Since it is supposed to be an accurate representation of data, you cannot select only the best performing patients. CMS has provided a lot of clarification about this in the last couple of months.


2018 is the first year practices are being graded on their cost performance. Although this information was provided in 2017, it wasn’t included as part of the overall score. In 2018, there are two measures: TPCC (Total Per Capita Cost – attribution plurality of primary care svcs – specialty-only groups will have patients who fall into this category) and MSPB (Medicare Spending Per Beneficiary – plurality of Part B services billed). Groups where the Eligible Clinician is not attributed any Cost measures will not be calculated a Cost performance score. In 2019, there will be eight new episode-based measures added.

Keep Good Records

It is very important for all to keep good documentation records, and CareOptimize highly recommends having an audit binder. CMS can audit practices up to 6 years after the program year in which you attested, so for PY 2017, you could be audited to 2023. Documentation that should be included in your audit binder includes proof from the registry stating your data was successfully submitted to CMS and a copy of your Security Risk Assessment report that was completed or reviewed, along with the date of completion. The same SRA report can be used and updated year to year. CMS has provided clear breakdowns per measure on what should be included in your audit binder on their website:


For 2018, you do need to be on a 2014 or 2015 certified EHR. If you are looking at an upgrade, such as moving from a 2014 to a 2015 certification, you do need to keep documentation supporting the time period in which you are attesting in your audit binder.

For all measures submitted in the Quality/PI categories, we highly recommend storing that year’s measure details in your audit binder as well as documented workflow used. Include screenshots within the EHR. It doesn’t have to be for specific patients, but you do need to be able to show how the providers are capturing the info. For PI measures, an ONC certified EHR is required to complete the report, which should be included, with numerator and denominator calculations, vendor logo, and timeframe in which you are attesting.

For additional measures within PI reporting, specifically specialized registry reporting and public health measures, it is critical to have documentation from state agencies including emails, screenshots, or receipts showing active engagement.

The CEHRT Bonus in Improvement Activities is a yes/no measure, and you need to include screenshots of the activity being completed for your attestation time period.

What 2019 looks like

The 2019 MIPS period has now started. MIPS 2019 includes two 12-month segments. The timeframe currently posted on the CMS website is October 1, 2017 to September 30, 2018. The second timeframe will be October 1, 2018 to September 30, 2019. Some changes:

  • Quality category now makes up 45%, a lower rate than it previously had, and Cost is 15%.
  • Exceptional performance threshold is now 75 points.
  • CMS is sticking with their decision to have a 2015 CEHRT requirement, which must be in place at least one day during the reporting period.

We can learn a lot from previous years. CMS reported that 93% of MIPS Eligible Clinicians received a positive payment adjustment and 95% avoided a negative adjustment. They have been quite good at predicting trends for the future. For 2018, they predict only 74% of clinicians would earn a score higher than 70% qualifying for the exceptional performance threshold.

Minimum points are increasing from 3 to 15. Distribution of points is also different with the Cost category being implemented and Quality having a smaller percentage. The same trend is expected to continue in 2019, with a minimum point increase to 30 points.

There is an increase in Eligible Clinicians for 2019. The threshold is the same (>$90,000 billed to Medicare, >200 services to Medicare beneficiaries, and > 200 covered professional services), but if you meet one, but not all conditions, you can still opt in for 2019. (Keep in mind once you have opted in, you can’t change it for the applicable performance period.) This will help increase the number of organizations participating and working toward attestation and the possibility of potential positive adjustment.

If you are actively working on 2018 MIPS submission, you should still be looking toward 2019, since there are areas needing work now that will affect your scores down the line. Right now, you should be:

  • Actively reviewing measures (not all will be available for 2019 – make sure to note which will and will not)
  • If you’re working toward that 75-point threshold for 2019 reporting year, education and retraining are extremely important.
  • Understand changes coming and who might benefit, with the additions of new clinicians that can come in as well as the opt-out.
  • Plan your upgrade if you are not already on a 2015 CEHRT.
  • Implement and train on risk adjustment coding. This is where clinicians can actively engage in Cost category to help impact it by simply accurately documenting chronic conditions, which can greatly help improve performance.

Ensuring you keep good records, staying up-to-date on CMS guidelines (www.cms.gov), and getting the help you need will all help you reach you attestation goals. For more information, please contact CareOptimize at info@careoptimize.com, call 855-937-8475, or visit our website www.careoptimize.com.