How is MIPS Score Calculated?

Find Out in 10 Simple Steps

The Quality Payment Program under MACRA came into effect on Jan 1st, 2017. All eligible clinicians are required to participate in this program under one of the three tracks: Merit-based Incentive Payment System (Traditional MIPS), MIPS Value Pathways (MVP), or Advanced Alternative Payment Models (Advanced APMs). All 2024 eligible clinicians (ECs) will earn a performance-based payment adjustment (positive or negative) towards their 2026 Medicare payments. This payment adjustment will be based on the Composite Performance Score (MIPS Score) earned by the clinicians on the measures reported under each of the four performance categories (Quality, Promoting Interoperability, Improvement Activities, and the CMS-controlled Cost).

MIPS eligibility requirements have undergone a few changes for 2024 compared to the previous performance year. The Low Volume Threshold (LVT) and the eligibility determination periods remain the same. The point values for Quality, PI, IA, and the Cost categories are also the same for 2024 as last year. The PI category was modified to require at least 180 continuous days. However, CMS has removed most of the bonus items except for the Small Practice bonus applied to the Quality category for practices of 15 or fewer providers. The Exceptional Performance scoring ended with the 2022 performance year, making 2024 the most difficult performance year for MIPS.

MyMipsScore simplifies all the changes that impact the 2024 MIPS Score calculation into 10 simple steps to serve as your pocket guide for MIPS scoring.

MIPS Overview: MIPS 2024 Performance Category Weights, Option to Opt-In, and Flexibility for Small Practices

STEP 1: Reporting as Individual, Group, MIPS-APM, or Facility-Based Clinicians

STEP 2: Specialty Measure Sets

STEP 3: Improvement Activities (IA) Special Considerations

STEP 4: Improvement Activities Scoring

STEP 5: Promoting Interoperability (PI) - Exclusions and Exceptions

STEP 6: Promoting Interoperability Scoring

STEP 7: Cost Category Measures and Scoring

STEP 8: Quality Weight, New Terminology, and Measure Selection including MVPs

STEP 9A: Quality Measure Data Requirements

STEP 9B: Quality Score Calculation: Measure Achievement and Bonus Points

STEP 10A: Final MIPS Score Calculation

STEP 10B: MIPS 2024 Payment Adjustment 

The MIPS Score, also known as Composite Performance Score (CPS) will be calculated from data reported by practices under the four performance categories to CMS. The category weights remain same as the previous year:

• Quality - 30%

• Promoting Interoperability (PI) - 25%

• Improvement Activities (IA) - 15%

• Cost - 30%

The combined weights for all performance categories equal 100. Computing the MIPS score involves tallying up points gained in each performance category and the corresponding category weight. The 2024 MIPS performance year is going to be the most challenging performance year yet, with a minimum threshold score of 75. Increasingly stringent benchmarks for Quality measures and a 180-day minimum for the PI category add to the complexity. MIPS Value Pathways (MVPs) is still available as an optional method for reporting Quality measures.

DETERMINING PRACTICE FINANCIAL EXPOSURE

Assessing the potential financial risks and rewards associated with the MIPS program is advisable. It will be very difficult to determine an upside potential for positive payment adjustments for 2024 performance year due to the changes in the scoring methodology CMS will use.  If you're eligible for MIPS (with >$90,000 in annual Part B reimbursement), you'll have the capacity to identify the absolute dollars at stake for not submitting data. You will need to forecast the Medicare Part B annual reimbursement your practice will receive in 2026 and deduct 9%, (e.g., $200,000 of reimbursement = $18,000 penalty). Our team can help you to optimize your overall MIPS score and maximize your ability to achieve incentives.

OPT-IN OPTION

Opt-In is available to eligible clinicians/groups in 2024 who meet at least 1 of the 3 Low Volume Threshold (LVT) criteria. A few important points to note are:

• Must be Opt-In eligible for the entire performance year (Opt-In status is shown on the Qpp.cms.gov eligibility web page).

• MIPS payment adjustment would apply if you Opt-In

• The performance will be published on Care Compare

  [Read more about MIPS Opt-In]

FLEXIBILITY FOR SMALL PRACTICES

Practices with ≤ 15 eligible clinicians (ECs) can take advantage of additional flexibility available to Small Practices in 2024:    

a. Small Practice Bonus (6 points to the Quality category ) - Small practices (1-15 ECs) will be awarded 6 points added to the aggregate Quality Numerator. After the bonus is applied, the Quality weighted score will NOT increase by 6 points. For instance, if the totals for the numerator and denominator for the Quality category is 40/60, the bonus points will be applied to the numerator before calculating the Quality Percent Score, making it (40+6)/60 = 46/60. To earn this bonus, practices need to submit data for at least one Quality measure.

b. Automatic Reweighting for Promoting Interoperability (PI) Category - The PI category will be automatically reweighted for Small Practices unless they submit the data for it.

c. Data Completeness Requirement Not Met - Under the Quality category, a Small Practice would earn 3 points for the measure that fails data completeness of 75% (was 70% in 2023). However, practices with 16 or more eligible clinicians will receive ZERO points.

d. Double Weight for Improvement Activities – Small Practices are awarded double the points for medium and high-weight activities, thus reducing the number of activities they need to report.

An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). In comparison, a group is defined as a set of clinicians (two or more, identified by their NPIs) sharing a common TIN, irrespective of specialty or practice site.

REPORTING AS INDIVIDUALS

• The data will need to be reported for every eligible clinician in the group for all applicable MIPS performance categories. (No data submission is required for the Cost category.)

• MIPS score will be calculated based on the individual performance reported, and the payment adjustment will apply to each individual.  

• Eligible clinicians can submit MIPS data as Individuals via a combination of collection types for the Quality category: EHR (eCQMs), Registry (MIPS-CQMs, QCDR measures), and Medicare Part-B Claims measures.
  
  

REPORTING AS A GROUP

• Data will need to be aggregated at the group level for each of the MIPS categories and then reported.

• All the eligible clinicians in the group will get one MIPS score based on the group’s performance.

• Small Practices (2-15 eligible clinicians) can report as a group using Claims measures ONLY if they submit data for another performance category as a group. CMS recognized that not all Small Practices that report Medicare Part B claims measures intend to participate as a group. Therefore, CMS will only calculate a group-level quality performance category score from Medicare Part B claims measures if the practice submits data for another performance category (PI or IA) as a group, signaling their intent to participate as a group.

• Quality data can be reported via a combination of collection types for the Quality category: EHR (eCQMs), Registry (MIPS-CQMs, QCDR measures), Medicare Claims measures (for small groups only), and CAHPS for MIPS (counts as one quality measure)

• For Groups of 16 or more, an additional measure will be applicable: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate. CMS will calculate the score from the Administrative Claims data and apply the score to the Quality category. No additional effort is required.

• Rules and options available for groups also apply to Virtual Groups (except for the low volume threshold)
  
  

REPORTING AS FACILITY-BASED CLINICIANS or GROUPS

MIPS-eligible providers can check their eligibility to utilize facility-based scoring as individuals or groups using the QPP Participation Status Tool. The qualifying clinicians and groups may have the option to use facility-based measurement scores for their Quality and Cost performance categories.

Facility-based clinicians will automatically receive Quality and Cost performance category scores as an individual based on their facility’s FY 2024 Hospital VBP Program score, even if they do not submit the data for PI and IA performance categories.

In comparison, the facility-based groups will need to submit PI and IA performance categories data as a group to receive Quality and Cost based on their attributed facility. The best MIPS score out of the two will determine the Payment Adjustment.

Facility-based measurement scoring will be used for Quality and Cost performance category scores when:

• Clinicians/groups are identified as facility-based; and

• Can be attributed to a facility with a Hospital Value-Based Purchasing (VBP) Program score for the 2024 performance period; and

• The Hospital VBP score results in a higher score than the MIPS Quality measure data you submit and MIPS Cost measure data that CMS calculates for you.

  
  

REPORTING AS A MIPS-APM

The MIPS score for MIPS APM participants will be calculated using the APM Scoring Standard. The performance category weights have been made uniform for all the MIPS APMs. That means the performance category weight distribution stays the same for the Medicare Shared Saving Program (MSSP), Next-Gen ACO, and the Other APMs. 

In addition to the MIPS APM participants, the APM Scoring Standard will also apply to the participants of dual-status APMs (Advanced APM and MIPS-APM) who are not deemed to be a Qualifying Participant (QP) or Partial QP. It will also apply to participants who qualify for Partial QP status and choose to participate under MIPS. The APM Scoring Standard takes precedence for MIPS score calculation for clinicians reporting both as a Group/Virtual Group and as a MIPS-APM.  

MIPS APM participants will also have the option to participate in the APM Performance Pathways (APP).

REPORTING AS AN MVP

In 2024, eligible clinicians will also have the option to report under the specialized MIPS Value Pathways program. CMS aims to reduce the overall burden of MIPS reporting by providing preselected, specialty-specific measure sets. This is analogous to a restaurant offering a select menu of certain items a customer must choose from, with no substitutions. 

The MVP program starts with the MIPS-eligible provider(s) registering to declare their intention to report with the MVP program. CMS has provided a detailed explanation of the MVP registration process. Providers can participate in the MVP program as individuals, Groups, or a combination of a Group and Subgroup.

There are 16 MVPs to choose from in 2024. Download the 2024 Proposed and Modified MVPs Guide

There are no specific MIPS requirements based on the specialty of an eligible clinician. However, the number of required measures in the Quality category may vary based on the specialty. Most providers are required to report 6 Quality measures with at least 1 Outcome measure (or High Priority measure if no Outcome measure is available). Providers can either pick the 6 measures from the available specialty-specific measure sets defined by CMS or pick any 6 applicable measures. In case a specialty-specific measure set has less than 6 measures, providers will not be penalized for reporting <6 measures as long as they report ALL the measures in that measure set.

CMS has grouped measures by specialty to make it easier for providers to find relevant ones. However, measures outside the specialty set can also be reported if they are relevant to your patient mix.

The Improvement Activities performance category rewards clinicians for delivering care that emphasizes care coordination, patient engagement, and patient safety. For 2024, data for a minimum of 90 continuous days will need to be reported for the IA category.

You may be eligible to receive special scoring considerations under this category if your practice meets specific criteria:

• Your practice is in a rural area or a health professional shortage area (HPSA)

• Yours is a Small Practice (has 15 or fewer eligible clinicians)

• You are a non-patient-facing clinician

If any of the above situations apply to you, you will be awarded double the points (20 points for a medium-weight activity and 40 points for a high-weight activity) for all the Improvement Activities you chose to report. A combined score of 40 points will maximize the IA category score.

Providers can also earn full credit for the IA category if they attest to participating in a Patient-Centered Medical Home (PCMH) during the 2024 submission period.

You must attest that you completed one or more out of 106 Improvement Activities available in 2024. You can earn a maximum of 40 points for this category (it carries 15% weight toward the final MIPS score). Improvement Activities are divided into medium-weight and high-weight activities. High-weight activities have twice the weight of the medium-weight activities and, therefore, count twice as much towards the final MIPS score (marked with the H icon in MyMipsScore).

NOTE: A Group or virtual group can attest to an improvement activity when at least 50% of the clinicians (in the group or virtual group) perform the same activity during any continuous 90-day period during the 2024 performance year.

The Promoting Interoperability (PI) performance category assesses the meaningful use of HTI-1 Certified EHR Technology under the Quality Payment Program (QPP). Under certain circumstances, specific exclusions and exceptions are available for MIPS-eligible clinicians.

EXCEPTIONS (Applicable at Category Level)

Based on provisions in the 21st Century Cures Act and MACRA, CMS will reweight the PI category to 0%, and its weight (25%) will be assigned to the Quality performance category in case of automatic reweighting and reweighting by hardship exception application.

EXCLUSIONS (Applicable at Measure Level)

Eligible clinicians who are not automatically exempted or claim the hardship exception must report on all the required measures under the four objectives or claim an exclusion to earn any score in the PI category. These objectives are:

• ePrescribing (1 measure)

  • PDMP attestation for at least 1 patient

• Health Information Exchange (4 measures)

  • Attest to using an HIE for sending health data

  • Attest to using an HIE for receiving health data

  • Perform a bi-directional patient information exchange electronically between providers

  • Attest to being a part of the TEFCA HIE exchange

• Provider to Patient Exchange (1 measure) - *No exclusion available*

• Public Health and Clinical Data Exchange (Report on the 2 required measures and get a bonus if you report on the 3 additional public health measures)

NO EXCLUSION is available for Security Risk Analysis (SRA) and Safety Assurance Factors for EHR Resilience (SAFER) Guides measures. These measures are not scored but must be completed to earn a PI category score. Providers will also need to submit Actions to Limit or Restrict Interoperability of CEHRT Attestation (renamed to distinguish it from the Cures Act Information Blocking requirements).

HTI-1 CERTIFIED EHR REQUIRED

Eligible clinicians must use an HTI-1-certified EHR to submit PI data. For the submission to be valid, the EHR must acquire the HTI-1 Certification by the last day of the chosen 180 continuous day performance period. However, the requisite HTI-1 functionality must be available throughout the entire performance period.

PI UPDATES: OBJECTIVES AND MEASURES FOR 2024

Beginning in 2024, the performance period for the PI Category has increased to a minimum of 180 continuous days within the calendar year (previously a minimum of 90 continuous days).

Clinicians must report on all the required measures (except the bonus measures) across all the objectives or claim an exclusion (when applicable) to earn a score in the PI category. A numerator of 1 is required for each measure being reported as a numerator/denominator to earn a score in the PI category. Each measure has different maximum points assigned, which will change when exclusions are claimed due to the reallocation of points.

Not attesting ‘YES’ to SRA or SAFER requirements will earn a PI score of ZERO.

BONUS POINTS

The modified structure for the PI category offers an opportunity for 5 bonus points under the Public Health and Clinical Data Exchange objective.

MAXIMUM POINTS

You can only earn a maximum of 100 points for the PI category, even though the total points add up to 105. If you earn more than 100 points, you will receive the maximum possible score of 25 for the PI category toward your final MIPS score.

REWEIGHTING WHEN EXCLUSIONS CLAIMED

Upon claiming an exclusion, the points for the measure will be assigned to another measure within the PI category keeping the total maximum points the same.

• e-Prescribing exclusion: When a clinician qualifies for exclusion from reporting this measure, the 10 points will be redistributed to the Health Information Exchange objective equally, making it 40 points.

• Support Electronic Referral Loops by Receiving and Incorporating Health Information exclusion: The weight will be reallocated to the Support Electronic Referral Loops by Sending Health Information measure within the Health Information Exchange objective making it worth 30 points.

• Support Electronic Referral Loops by Sending Health Information exclusion: The weight will be reallocated to Support Electronic Referral Loop by Receiving Health Information measure within the Health Information Electronic objective making it worth 30 points.

• Exclusion claimed for both HIE measures: If the exclusion is claimed for both Support Electronic Referral Loop by Receiving Health Information measure and Support Electronic Referral Loops by Sending Health Information measure, 30 points will be reallocated to the Provide Patients Electronic Access to Their Health Information measure, making it worth 55 points.

• Public Health and Clinical Data Exchange exclusion: Exclusion can be claimed for just one or both the public health /clinical data registries required to be reported to. If the exclusion is claimed for just one, then the one being reported will carry all 25 points. If the exclusion is claimed for both, the 10 points are allocated to the Provide Patients Electronic Access to Their Health Information measure, making it worth 50 points.

The Cost performance category has increased to 30% for the 2024 performance year. CMS will calculate the score for the Cost category from the Medicare Administrative Claims data for the entire calendar year 2024. So, you don’t need to submit any data. There are a total of 29 measures (27 episode-based measures + MSPB-C + TPCC). The measures would be scored for a provider or practice only when the scoring criteria are met.

Each measure will be scored out of 10 points based on the measure benchmarks. Only the measures for which your organization meets the case-minimums will be scored.

The Quality category carries the maximum weight toward the final MIPS score and requires data to be reported for the full calendar year (Jan 1, 2024 – Dec 31, 2024). Quality category weight is 30% for 2024 unless you apply for a PI hardship exception (see Step 5). In that case, the PI category weight of 25% is assigned to the Quality category making the Quality category weight 40%.

COLLECTION TYPES, SUBMISSION TYPES, AND SUBMITTER TYPES

The terminology for Quality Measure submissions is three-fold :  

1. COLLECTION TYPES (Measure Types Available)

• eCQMs (EHR measures or electronic Clinical Quality Measures)

• MIPS CQMs (previously known as Registry measures)

• QCDR measures

• Claims measures (available only to small practices of 1-15 eligible clinicians submitting as individuals, groups, or virtual groups)

• CAHPS for MIPS survey (available only to groups)

  NOTE

  • The benchmarks for each collection type will vary even for the same measure. eCQMs need to be calculated using the 2024 specifications provided by CMS from an HTI-1 Certified EHR. Old CQM versions will not be acceptable.

2. SUBMISSION TYPES (Mode of Submission)

• Direct: The direct submission type allows users to transmit data through a computer-to-computer interaction (API embedded in the EHR).

• Log in and Upload: Enables users to upload and submit data in the form and manner specified by CMS with a set of authenticated credentials (EIDM account).

• Medicare Part B claims

3. SUBMITTER TYPES (Entity Submitting the Data)

• Individual MIPS eligible clinicians

• MIPS eligible Group (and virtual group)

• Third-party Intermediary acting on behalf of clinician or group

SELECTING QUALITY MEASURES

MULTIPLE COLLECTION TYPES ALLOWED: You can mix and match all applicable collection types to submit 6 measures unless your specialty set has less than 6 measures (see Step 2). Out of these 6 measures, one measure must be an Outcome Measure or a High Priority measure if no outcome measure is applicable to your practice.

• NOTE

  • No bonus points for selecting additional high-priority or outcome measures from 2024.

  • The absence of an Outcome or High Priority measure will result in a ZERO for the Quality category.

Quality measures under MIPS have been sub-categorized into Efficiency, Intermediate Outcome, Outcome, Patient Engagement /Experience, Process, and Structure measures. High Priority Measures have been tagged as (P) in the MyMipsScore app.

There are a couple of things you need to know before you start entering your data for Quality category:

Data Completeness Requirements: A minimum of 75% data completeness is required to achieve maximum points for each measure. That means you must report that at least 75% of your total patients meet the measure's denominator criteria, regardless of payer (Medicare and Non-Medicare), except for Claims for which only Medicare Part B beneficiaries count. Less than 75% completeness will yield ZERO points (Small Practices will still get 3 points) for all submission methods.

• NOTE: New Quality Measures (Class 4 Measures) that meet the Data Completeness will have a 7-point minimum score for 2024.

Case Minimum of 20: For all the Quality measures, you must at least report 20 cases, i.e., the denominator must be 20 or more for you to earn more than 3 points for that measure. For instance, a Numerator/Denominator of 18/18 might yield only 3 points, but a Numerator/Denominator of 18/20 could yield 10 points.

Measure Benchmarks: Scores for two different measures can be very different even with an identical performance rate based on the benchmark and bonuses available for the measures. We encourage you to select as many measures as possible and enter data for all the measures.

a. Determine the maximum points. If you are reporting a Specialty Measure Set that has less than 6 measures, your max points would be less than 60 (no. of measures x 10). Whenever any of the three Administrative Claims Measures are applicable to your group, your max points will go up by 10 points per applicable measure. For all other providers, the maximum number of points will be 60 (based on 6 measures). 

b. Calculate Achievement Points: Eligible clinicians can earn a maximum of 10 points for each of the six measures. The collection type and corresponding benchmark determine each measure's points earned. For certain measures that are topped out for the second consecutive year, the maximum points have been capped at 7 points. These measures will not earn 10 points, even after meeting all performance criteria.

c. CAHPS for MIPS Achievement Points: Groups and Virtual Groups can report CAHPs for the MIPS survey as one quality measure towards the required 6 measures. The survey comprises 10 Summary Survey Measures (SSMs) where each SSM has its own benchmark. The average of these SSMs will determine the performance rate for the CAHPS for MIPS. In addition to the achievement points,

d. Quality Improvement Scoring will be calculated for the eligible clinicians and groups that show improvement in 2024 Quality category performance as compared to 2023 performance. The improvement score will be calculated at the performance category level so eligible clinicians can select different Quality measures in 2024. Up to 10 percentage points could be earned for showing an improved performance in the Quality category. The improvement score will be calculated as long as the previous year’s performance is available for comparison. 30% of the performance category score will be considered as the base. Improvement will be calculated from there. 

 Improvement Percent Score = (increase in quality performance category achievement percent score from prior performance period to current performance period / prior performance period quality performance category achievement percent score) x 10

e. Small Practice Bonus (6 points)

All clinicians who submit data as Individuals, Groups, Virtual Groups, or APM entities will have 6 points added to their Quality Category (numerator) if they qualify as small practice (have 1-15 eligible clinicians).

f. Quality Performance Category Score: You cannot earn more than 100% of the maximum points for a performance category. If 60 is the maximum score for you and you earn a total of 66 points including bonuses, your score will be capped at 60 points. You will get full credit for the Quality category (Quality category score of 30 points) towards the calculation of your final MIPS Score.

Note: If you are a group of 16 or more providers, CMS will calculate your performance on all the applicable Administrative Claims measures out of the 3 available measures. It will be scored only if your group meets the minimum case requirement for this measure and will be added to your Quality score by CMS to determine the final MIPS score.

The Quality category points will be expressed as a percent which will be calculated as: Quality Performance Category Percent Score = [(Total Achievement Points + Small Practice Bonus Points if applicable) / Total Applicable Measure Points] x 100 + Improvement Percent

For example: Quality Performance Category Percent Score = [(40 +2+1+6)/60] x100 + 9%

= 81.67% + 9%

 = 90.67%

This will then be multiplied by the Quality category weight to arrive at the Quality category score.

= 90.67% x 30

=27.20

REWEIGHTING

In case a performance category cannot be scored due to lack of applicable measures (Quality), inability to meet case minimum requirements or unavailability of a benchmark (Cost), lack of control over EHR, or lack of patient-facing interactions (PI), or extreme circumstances (IA), the weight will be redistributed to other performance categories. The MIPS eligible clinicians /groups/virtual groups must submit data for at least 2 performance categories in order to get a MIPS score. As long as two performance categories can be scored, the weight for other performance categories unable to be scored would be allocated to the two performance categories being scored.

In the rare occurrence of inability to submit the data for even two performance categories (natural disasters), the affected clinicians will be assigned a score equal to the performance threshold (75 points) to prevent any negative payment adjustment. 

COMPLEX PATIENT BONUS POINTS (Max 10 points)

Up to 10 bonus points can be earned for the treatment of complex patients. This would be determined based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dually eligible (Medicare + Medicaid) patients treated. You must submit data for at least 1 performance category to earn this bonus.

Complex Patient Bonus Points will be calculated as:

• For individuals and groups: (Average HCC risk score + Dual Eligible Ratio) x 10

• For Virtual Groups: (Weighted Average HCC risk score of each TIN + Dual Eligible Ratio) x 10
  
  

FINAL MIPS SCORE - COMPOSITE PERFORMANCE SCORE

Final MIPS Score = IA Weighted Score + PI Weighted score + Quality Weighted Score + Cost Weighted Score + Complex Patient Bonus

Based on your 2024 MIPS score, CMS will apply a maximum of +/-  9% payment adjustment to your 2026 Medicare Part B allowed charges. [READ: How MIPS Calculators Work?]

Base Payment Adjustment Range:  +/-  9%

For MIPS Score 0 to 18.75 Points: Full penalty of -9% is applicable. Maximum penalty determined for the performance year applies if the score is at or below ¼th of the Performance Threshold for that year (75 x ¼ = 18.75).

For MIPS Score 18.76 – 74.99 Points: Negative payment adjustment gradually decreasing on a linear sliding scale from -9% to < 0% will apply

For MIPS Score of 75 Points: Payment adjustment of 0% at the Performance Threshold of 75.

For MIPS Score 75.01 – 100 Points: Providers with scores in this range will receive a positive payment adjustment which is scaled from 0% to 9% to provide a maximum adjustment of 9% at the MIPS score of 100. A scaling factor will be used to equitably distribute every single cent of the penalties collected.

Make MIPS easy for your practice. Use MyMipsScore. 

Keeping track of submission methods, measure benchmarks, topped-out measures, case minimums, and bonus requirements in addition to care delivery can be simple with MyMipsScore. Monitor your MIPS score regularly so you can make timely adjustments and maximize your payment adjustments.