If you report MIPS data in as an individual, your payment adjustment will be based only on your performance. An individual is defined as a single clinician, identified by their individual National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).

If you report only as an individual, you'll report measures and activities for the practice(s)/TIN(s) under which you are MIPS-eligible and be assessed across all 4 performance categories at the individual level. Your payment adjustment will be based on your Final Score derived from the 4 MIPS performance categories.

If you report MIPS data with a group, your payment adjustment is based on the group’s performance. A group is defined as a single TIN with 2 or more clinicians (at least one clinician within the group must be MIPS eligible) as identified by their NPI, who have reassigned their Medicare billing rights to a single TIN.

If you report only as a group, you must meet the definition of a group at all times during the performance period and aggregate the group’s performance data across the 4 MIPS performance categories for a single TIN. Each MIPS-eligible clinician in the group will receive the same payment adjustment based on the group's performance across all 4 MIPS performance categories.

If you wish to report as both an individual and a group, MIPS-eligible clinicians can report data as an individual and as part of a group under the same TIN. In this instance, the clinician will be evaluated across all 4 MIPS performance categories on their individual performance and on the group’s performance, with a final score calculated for each evaluation. The clinician will receive a payment adjustment based on the higher of the two scores.

A Virtual Group is a combination of two or more Taxpayer Identification Numbers (TINs) made up of the following:

• Solo practitioners who are MIPS eligible (a solo practitioner is defined as the only clinician in a practice); and/or

• Groups that have 10 or fewer clinicians (at least one clinician within the group must be MIPS eligible). A group is considered to be an entire single TIN.

In order to participate in MIPS as a virtual group for the 2019 performance period, virtual groups were required to submit an election to CMS via e-mail by December 31, 2018. As part of the election process, virtual groups identify an official virtual group representative who is responsible for submitting a virtual group election. Virtual groups must have a formal written agreement among each solo practitioner and group that is part of the virtual group.

TINs participating in MIPS at the virtual group level must meet the definition of a virtual group at all times during the performance period. Virtual groups must aggregate their performance data across the multiple TINs within the virtual group for all 4 performance categories in order for their performance to be assessed and scored at the virtual group level. Each clinician (NPI) who is part of a virtual group will receive a final score based on the performance of the virtual group; however, only clinicians who are MIPS eligible will receive a payment adjustment. The payment adjustment is applied to each MIPS eligible clinician based on the performance of the virtual group, regardless of any data that may be submitted at the individual or group level.

Your eligibility is based on your:

• National Provider Identifier (NPI)

• Associated Taxpayer Identification Numbers (TINs)

A TIN can belong to:

• You, if you’re self-employed

• A group or practice

• An organization like a hospital

When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination. If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations. Each TIN/NPI combination is evaluated for MIPS eligibility. We’ll use TINs to evaluate groups for eligibility.

In order to be MIPS eligible, a clinician must:

1. Identify on Medicare Part B claims as a MIPS eligible clinician type

2. Have enrolled in Medicare before 2019

3. Not be a Qualifying Alternative Payment Model Participant (QP)

4. Exceed the Performance Year 2019 low-volume threshold
   

• As an individual when reporting individually, or

• At the group level by being in a practice that exceeds the low-volume threshold when reporting as a group or virtual group, or

• As a MIPS APM participant that exceeds the low-volume threshold at the entity level

Clinicians who don’t meet these requirements are exempt from MIPS.

• Physicians (including Doctors of medicine osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)

• Osteopathic practitioners

• Chiropractors

• Physician assistants

• Nurse practitioners

• Clinical nurse specialists

• Certified registered nurse anesthetists

• Physical therapists

• Occupational therapists

• Clinical psychologists

• Qualified speech-language pathologists

• Qualified audiologists

• Registered dietitians or nutrition professionals

Beginning in Performance Year 2019, the low-volume threshold includes 3 aspects of covered professional services:

1. Allowed charges

2. Number of beneficiaries who receive services

3. Number of services provided

Clinicians and groups fall under the low-volume threshold and are exempt from MIPS if they:

• Bill $90,000 or less in Medicare Part B allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), or

• Provide covered professional services for 200 or fewer Part B-enrolled individuals, or

• Provide 200 or fewer covered professional services to Part B-enrolled individuals

If you're exempt from MIPS for Performance Year 2019, you're not required to participate. You can choose to opt-in to MIPS if you exceed 1 or 2 of the low-volume threshold criteria. Check your status throughout the year if you make any changes that may affect your eligibility.

CMS understands that circumstances may be beyond your control and can make it difficult for you to meet program requirements. They provide exceptions for these cases. For Performance Year 2019, you can apply for the:

• Promoting Interoperability Hardship Exception

• Extreme and Uncontrollable Circumstances Exception