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MIPS: Clarifying Some of the Confusion

MIPS: Clarifying Some of the Confusion

PTs, OTs, and SLPs became eligible to participate in the Merit-based Incentive Payment System (MIPS) program this year. While the opportunity to participate and earn incentive payments for Medicare Part B billing in 2021 is positive for the rehab industry, understanding the ins and outs of the program has been a challenge for all.

Following are answers to some of the trickier aspects of the program:

  1. Are groups (as defined by Tax ID Number) that meet or exceed all three aspects of the low-volume threshold required to participate in MIPS in 2019?

No. Individual clinicians (as identified by NPI/TIN combination) who exceed all three aspects of the low-volume threshold are required to participate in MIPS in 2019 or be subject to the full 7 percent penalty in 2021. Groups that exceed the threshold may choose to participate in MIPS this year.

For more information, refer to the 2019 MIPS Participation and Eligibility Fact Sheet.

  1. Can therapists treating Medicare Part B beneficiaries in hospital outpatient departments participate in MIPS?

No. MIPS is a quality payment program that applies to PTs, OTs and SLPs who bill on professional claims (e.g., the CMS 1500 or 837p) only – that is, those in “private practice.” Participation and performance in MIPS are identified and tracked via the therapist’s NPI as it appears on the claim, and therapy services billed to Medicare Part B on a UB-04 by institutional providers (e.g., hospitals, SNFs, rehab agencies) do not contain the individual therapist’s NPI.

  1. Can a therapist who owns an outpatient practice participate in MIPS this year if none of the therapists in the practice meet all three aspects of the low-volume threshold, but all meet at least one?

Yes. Individual clinicians or groups who meet or exceed one or two aspects of the low-volume threshold can “opt in” to the program in 2019. Opting in is a decision that is made on an annual basis, and once the decision is made, you are “in” the program for the entire calendar year (in other words, you can’t change your mind). As of this posting, the opt-in process is still being developed by CMS. Clinicians and groups who have decided to opt in should already be collecting quality data and either partnering with a Qualified Registry or Qualified Clinical Data Registry (QCDR) or reporting the data via the Medicare Part B claim (a reporting option available only to small practices, defined as those with 15 or fewer eligible clinicians).

  1. If a practice decides to participate in MIPS as a group, how many measures does each therapist (PT, OT and SLP) need to report?

CMS states that clinicians participating in MIPS must report data on six quality measures, one of which must be an outcome measure, or other high priority measure if an outcome measure is not available. If reporting as a group, the group selects six measures that all of the clinicians in the group can contribute data to, such that each measure is submitted on at least 60 percent of all patients to whom the measure applies. Some measures will apply to almost every patient (e.g., BMI and pain), while others will apply to select patients only (e.g., patients over the age of 65 [the Falls measures], those with a diagnosis of diabetes or patients with a hip impairment).

For example, if your practice/group selects measures 128 (BMI), 130 (Medications), 131 (Pain), 154 (Fall Risk), 155 (Falls Plan of Care) and 222 (FOTO Elbow/Wrist/Hand), the PTs and OTs would report on all of these measures on each patient to whom the measure applies since all measures are available for both PT and OT. If in your practice, patients with upper extremity impairments are evaluated and treated by OT, then measure 222 will likely only be reported by the OTs because the patients eligible for this measure will be treated by occupational therapy and not physical therapy.  The SLPs in this practice will report on measures 130 and 131, as those are the only two measures in this list of six that are available to SLPs.  (Refer to our Selecting Quality Measures white paper for more information.)

  1. How are improvement activities planned for this year reported to CMS?

Clinicians participating in MIPS, whether as individuals or as a group, must “attest” to completing the selected improvement activities for at least 90 consecutive days during the year. This can be done via a Qualified Registry or QCDR with the attestation capability or by logging in to the CMS Quality Payment Program website and attesting to activity completion (i.e., selecting a “yes” response for each activity completed). If participating as a group, one clinician can log in and attest on behalf of the group. (Refer to our “Improvement Activities” article for more information.)

For more information on MIPS, please visit:

Quality Payment Program

American Physical Therapy Association

The American Occupational Therapy Association, Inc.

American Speech-Language Hearing Association

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Quality, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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