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The Medicare Merit-Based Incentive Payment System (MIPS)

A Guide for Audiologists and Speech-Language Pathologists

NOTE: In response to the COVID-19 pandemic, CMS will apply the Extreme and Uncontrollable Circumstances Hardship Exception policy to all clinician subject to MIPS in 2020. This means that any clinician who did not report any data for the 2020 performance period will avoid a payment penalty in 2022. CMS is also reopening the hardship exception application for group practices, virtual groups, and alternative payment model entities who missed the previous 2020 deadline. The re-opened application deadline is March 31, 2021.

Groups and eligible clinicians who submit data in at least two MIPS categories will override the hardship exception and be eligible to earn a bonus from the exceptional performance bonus pool or potentially be subject to a penalty.

Effective January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) included audiologists and speech-language pathologists (SLPs) in the Merit-Based Incentive Payment System (MIPS). ASHA estimates less than 1% of members were required to participate in MIPS in 2020. The MIPS payment adjustment—applied in 2023 based on a clinician's performance in 2021—is +/- 9%.

MIPS participation is separate from the claims-based outcomes reporting requirement for Medicare Part B therapy services, often referred as 'functional limitation reporting' (FLR), which was eliminated for dates of service on or after January 1, 2019.

Navigating MIPS

  1. Find out if you're eligible to participate.
  2. If you're eligible, see if you meet any of the exemption criteria.
  3. If you're part of a group practice (two or more clinicians), decide whether you will participate as an individual or as a group.
  4. If you're not required to participate, learn how you can still voluntarily report or opt-in.
  5. If you're required to participate, find out what to do.

Who Must Participate? 

Audiologists and SLPs who exceed the low-volume threshold, are not otherwise exempt, and provide services to Medicare Part B patients in the following settings must participate in MIPS reporting.

  • Independent private practices
  • Group practices
  • University clinics not associated with a hospital medical center
  • Outpatient clinics not associated with a hospital medical center
  • Critical access hospitals (CAHs) that have elected Method II billing (check with hospital administration)

Clinicians working in facility-based settings (e.g., hospitals, skilled nursing facilities, etc.) do not have to participate in MIPS. MIPS reporting only occurs in settings where individual NPI numbers and Current Procedural Terminology (CPT) codes are indicated on claims. ASHA estimates less than 1% of members are required to participate in MIPS for 2020.

Clinicians can use the 2019 MIPS Eligibility Decision Tree [PDF] and the  Quality Payment Program Lookup Tool to help determine MIPS eligibility.

See also: How MIPS Eligibility is Determined

Low-Volume Threshold

To reach the low-volume threshold, a clinician must meet all three of the following criteria in a calendar year.

The individual clinician must

  • see 200 or more Medicare beneficiaries;
  • provide 200 or more covered professional services (defined as a single line item on the claim); AND
  • receive $90,000 or more in reimbursement from Medicare.

Clinicians can use the Quality Payment Program Lookup Tool to help determine whether you've met the low-volume threshold and are eligible for MIPS participation.

Exemption from MIPS Reporting

A clinician who provides Medicare Part B services in the appropriate settings can still be exempt from mandatory MIPS reporting for any one of the following reasons.

A clinician who is exempt from mandatory reporting for any of these reasons may choose to participate in the MIPS program in one of two ways—opting-in or voluntary reporting.

Opting-In or Voluntary Reporting

A clinician who is exempt from MIPS reporting can still participate in the program through voluntary reporting or by opting-in to MIPS.

Voluntary reporting allows you to practice reporting without being subject to MIPS incentive payments or penalties. This may be helpful if you are considering opting-in or if the MIPS program expands its mandatory reporting criteria to include more clinicians in the future. performance.

Opting-in to the MIPS program allows you to earn the MIPS incentive or risk the MIPS penalty. To opt-in, you can only exceed one or two of the three low-volume threshold criteria in addition to other criteria outlined by CMS. Opting-in might be attractive if you were previously successful under the Physician Quality Reporting System (PQRS). Keep in mind that opting-in subjects you to a positive, neutral, or negative payment adjustment based on your MIPS performance.

Contact CMS for information on how to opt-in or voluntarily report at QPP@cms.hhs.gov, 1-866-288-8292, or 1-877-715-6222 (TTY).

Group Practices: Choosing Individual or Group Reporting

Group practices (two or more clinicians) should decide whether clinicians will report as individuals, as part of the group, or both (individually and as part of the group). Keep in mind that mandatory reporting only applies to individual clinicians, not the group. 

If each individual clinician in the group is exempt from MIPS reporting, they are not required to report even if they collectively meet the reporting requirements as a group.

If any individual member of the group is a required to participate in MIPS, the practice can elect to report as a group, though it is not required. When a practice elects to participate in group reporting, all clinicians in the group must report. In this case, clinicians could report as both an individual and as a group. CMS will assess both the individual and group score and use the better score to determine the payment adjustment.

See also: MIPS Individual or Group Reporting and 2019 Group Participation Guide [PDF]

Group Practice Reporting Scenario

Scenario: Four physicians and two audiologists see Medicare Part B patients in a private practice. Each individual physician is required to report because they meet all MIPS eligibility criteria. However, the audiologists are not required to report because they are individually exempt. 

The private practice has several reporting options in this scenario:

  • The audiologists elect not to participate in MIPS and the physicians report as individuals, as required. The group is not reporting.
  • The audiologists participate voluntarily to gain experience with the program and the physicians report as individuals, as required. The audiologists would not be subject to the penalty or incentive. The group is not reporting.
  • The audiologists opt-in to MIPS and the physicians report as individuals, as required. Like the physicians, the audiologists could earn the incentive but also risk the penalty. The group is not reporting.
  • The practice determines they will report as a group. This means everyone in the group, including the audiologists, will be required to report.
    • The practice decides that all clinicians will participate as both individuals and as a group to improve the chances of earning a neutral or positive MIPS payment adjustment.

MIPS Participation and Performance Categories

MIPS participation and scoring starts over each calendar year. For example, the 2021 performance period begins January 1, 2021, and ends December 31, 2021. Payment adjustments based on 2021 reporting will only apply to Medicare payments in 2023. If you get a different score in the next calendar year (2022), it will only apply to payments made in 2024 and so on. You should begin reporting as close as possible to January 1 of each year to improve your chances of successful participation.

Clinicians participating in the MIPS program receive a composite score based on their performance on each of four performance categories—quality, improvement activities (IAs), promoting interoperability (PI), and cost.

Only two of the four MIPS performance categories apply to audiologists and SLPs in 2021—quality measures and improvement activities. The quality performance category makes up 85% and the IA category makes up 15% of the total composite performance score. The associated weights of the other performance categories will be redistributed to the quality and IA categories for scoring purposes.

See also: CMS 2019 Measures and Activities for Audiologists and SLPs [PDF]

Reporting Quality Measures

The quality performance category is based on quality measures developed through a qualified clinical data registry (QCDR) or with legacy measures formerly used in the Physician Quality Reporting System (PQRS). The legacy PQRS measures are primarily process-based—as opposed to outcomes-based—and are more general, such as tobacco-use screening and cessation intervention.

The quality performance category makes up 85% of a clinician's total composite performance score.

How it Works

Quality measures can be reported in a variety of ways, including through Medicare Part B claims, electronic health records (EHRs), or registries. Most audiologists and SLPs will likely report on their Medicare Part B claims, unless they are connected to a larger practice.

Each quality measure includes specifications that indicate when a clinician should report on that measure. These specifications include the service provided (based on CPT codes) and specific patient characteristics (for example, age or diagnosis).

To report on a quality measure, you will add specific MIPS-related G-codes to your claim form for all qualifying visits with a patient. A qualifying visit is when an encounter meets all the specifications required for reporting one or more quality measures.

Benchmark for Successful Participation: Clinicians must report on at least six measures and all qualifying visits for those measures. However, audiologists only have six measures and SLPs only have three available for reporting, so you must report on all measures available for all qualifying visits. To meet the benchmark, clinicians must successfully report on at least 60% of the qualifying patient visits. Successful reporting means that a MIPS quality data code (QDC) indicating performance met for that quality measure was included on the claim. If a quality action that is indicated as performance met is not taken for a minimum of 60% of the qualifying visits, the benchmark for successful participation in this performance category has not been reached.

2021 Quality Measures

The reporting period for the quality performance category is the 2021 calendar year. Reporting in 2021 will determine payment adjustments in 2023, which could be as much as +/-9% in the 2023 payment year.

Clinicians should report on all qualifying visits for at least six quality measures. There are nine quality measures for audiology reporting and five for SLP reporting. Audiologists can chose the six measures most relevant to their practice for reporting. SLPs will have to report all five measures when applicable.

Measures for audiologists:

  • #130: Documentation of Current Medications in the Medical Record
  • #134: Screening for Depression and Follow-Up Plan
  • #154: Falls Risk
  • #155: Falls Prevention Plan
  • #181: Elder Maltreatment Screen and Follow-Up Plan 
  • #182: Functional Outcome Assessment 
    • #226: Tobacco Use: Screening and Cessation Intervention
    • #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
    • #318: Falls: Screening for Future Falls Risk 
      • Note: This measure is only reported via certified electronic health record technology (electronic health record (EHR)) and not claims. If you do not use an EHR, do not report this measure. 

    See MIPS Quality Measures for Audiologists for measure specifications and reporting instructions.

    Measures for SLPs:

    • #130: Documentation of Current Medications in the Medical Record
    • #134: Preventative Care and Screening: Screening for Depression and Follow-up Plan
    • #181: Elder Maltreatment Screen and Follow-Up Plan 
    • #182: Functional Outcome Assessment
      • #226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
      • *deleted from MIPS, no longer in use as of January 1, 2020* #131: Pain Assessment and Follow-Up

      See MIPS Quality Measures for SLPs for measure specifications and reporting instructions.

      Reporting Improvement Activities

      Improvement activities (IAs) are activities that may not involve direct patient care but can improve the quality of care. An example of an IA is when a clinician implements extended office hours on evenings or weekends. This activity could help decrease the number of emergency room admissions. There are more than 100 CPIAs to choose from, giving audiologists and SLPs some flexibility in this category.

      The IA performance category makes up 15% of a clinician's total composite performance score.

      How it Works

      To receive credit for IAs, clinicians must attest that they have been completed through the Quality Payment Program (QPP) Portal. The list of IAs and information on attestation can be found on the CMS QPP website. It is important for clinicians to include documentation in their records to outline and support the actions they have taken to complete the IAs.

      Unlike the quality category, selection of IAs is largely driven by the unique circumstances of the clinician and not factors like CPT codes or patient characteristics.

      Benchmark for Successful Participation: Medicare assigns a medium weight (10 points) or high weight (20 points) to the IAs based on their difficulty and relevance to quality improvement. A clinician must earn 40 points by completing a combination of medium and/or high-weighted IAs to successfully participate in this category. Each IA must be performed during a single, continuous 90-day period (or longer) during the calendar year.

      A clinician can achieve 40 points by reporting:

      • 4 medium-weighted activities;
      • 2 high-weighted activities; or
      • 2 medium-weighted and 1 high-weighted activity.

      How do the Payment AdjustmentsApply?

      Depending on the outcome of 2021 reporting, a positive or negative payment adjustment of as much as 9% will be applied on all 2023 Medicare claims submitted for services provided by the individual clinician. Clinicians exceeding the benchmark for successful participation in each of the performance categories are eligible for positive payment adjustments and those who do not exceed the benchmark are subject to a negative payment adjustment.

      MIPS is tracked by the Taxpayer Identification Number (TIN) of the practice that submitted the claim with the National Provider Identifier (NPI) of the audiologist or SLP listed on the claim as the "rendering provider." This means that you must meet benchmark requirements in every practice that uses your NPI on the claim as the rendering provider.

      Other Performance Categories

      Although there are four performance categories under the MIPS program, only quality measures and improvement activities (IAs) currently apply to audiologists and SLPs, as outlined above. The other two categories—promoting interoperability (PI) and cost—do not currently apply due to a lack of relevant metrics for audiologists and SLPs.

      Promoting Interoperability (PI): PI refers to the meaningful use of electronic health records to improve clinician and patient access to care information. Audiologists and SLPs were not eligible for incentive payments under the old meaningful use program and there are no metrics currently associated with audiology or speech-language pathology services. As such, this performance category will not be applicable to audiologists and SLPs during the 2021 performance period. Its associated weight in the clinician's total composite performance score will be redistributed to the quality and IAs categories.

      Cost: This performance category measures a clinician's cost of care and compares it to a predetermined benchmark. This may be difficult to measure for audiologists and SLPs, as they do not control health care spending and care coordination in the same manner as primary care physicians. As such, this performance category will not be applicable to audiologists and SLPs during the 2021 performance period. Its associated weight in the clinician's total composite performance score will be redistributed to the quality and IAs categories.

      Resources

      Questions? Contact ASHA's health care policy team at reimbursement@asha.org.

      ASHA Corporate Partners