MIPS Scoring for PT/OT/ST in 2019

MIPS Scoring for PT/OT/ST in 2019

MIPS Scoring for PT/OT/ST in 2019

PTs, OTs and SLPs who participate in MIPS in 2019 (the “performance year”) will be subject to a payment adjustment to their Medicare Part B reimbursement in 2021 (the “payment year”). This payment adjustment can be positive, negative or neutral based on the individual clinician’s or group’s performance in the program.

For the 2021 payment year, the MIPS Performance Threshold is 30 points (out of 100). Individual clinicians and groups who achieve 30 total points will receive a neutral payment adjustment, below 30 receive a negative adjustment (penalty) and above 30 a positive one (incentive). Payment adjustments in 2021 can be as much as + or – 7%. (NOTE: Payment adjustments are “budget neutral,” meaning the incentive pool is equal to the penalty pool. Incentives are earned by eligible clinicians/groups based on performance relative to those who receive penalties for substandard performance.)

The eligible clinician’s or group’s performance in the Quality and Improvement Activities categories will be weighted and added together to determine the total performance score out of 100. Having a general understanding of scoring in both categories will help clinicians make informed decisions about MIPS participation, measure selection and process implementation.


Quality Measures for MIPS in 2019 will receive 1 to 10 points per measure, known as “measure achievement points.”

Each Quality Measure falls into 1 of 3 categories for scoring purposes:

  1. The measure meets data completeness criteria (reported on at least 60% of all eligible patients), has a benchmark and the volume of cases is sufficient (> 20 cases for most measures)
    • These measures receive 3 – 10 points based on performance compared to the benchmark
  2. The measure meets data completeness criteria, but either 1) does not have a benchmark, and/or 2) the volume of cases is insufficient (≤ 20 cases)
    • These measures receive 3 points
  3. The measure does not meet data completeness criteria
    • These measures receive 1 point, except for small practices (≤ 15 eligible clinicians) which continue to receive 3 points

Benchmarks for 2019 are established using 2017 MIPS performance data. Since PTs, OTs and SLPs were not eligible to participate in MIPS in 2017, several “therapy-only” measures do not have determined benchmarks, while measures that apply to many different clinicians (i.e., MDs, NPs, etc.) do have established benchmarks. Performance for each measure with a benchmark is broken down into deciles (10 equally sized groups), with each decile assigned a value between 3 and 10. For example with a non-inverse measure (better performance equals higher score), individual clinicians/groups who receive a score within the 1st or 2nd decile will receive 3 points; those within the 3rd decile will receive a score between 3 and 3.9; those in the 4th decile will receive a score between 4 and 4.9; etc.

“Topped Out” measures may be capped at 7 points. A topped out measure is one where performance is consistently high across providers such that meaningful distinctions and improvement in performance can no longer be made. In other words, almost everyone who submits a topped out measure does so successfully, with little to no room for further improvement.

CMS has published information on benchmarks and topped out measures for 2019 in the Quality Payment Program Resource Library.

  • Topped out measures for PT/OT/ST in 2019 with a 7-point cap include:
    • 130 – Claims/Registry
    • 131 – Claims only
    • 154 – Claims/Registry
    • 155 – Claims/Registry
    • 181 – Claims only
    • 182 – Claims only
  • Measures with no benchmark (scored at 3 points):
    • 182 – Registry
    • FOTO measures 217-223
    • 226 – Claims/Registry

The maximum number of achievement quality points a PT, OT or SLP may be awarded is 60 (i.e., 6 measures, each with maximum score of 10), whether reporting individually or as a group.

If an individual clinician or group submits fewer than 6 measures, they will be subject to the Eligibility Measure Applicability (EMA) Process.  CMS uses EMA to determine if there are additional applicable measures that could be reported.

  • If CMS finds no additional applicable measures, the clinician/group will not be held accountable for not submitting them, and the number of maximum points will be lowered for the Quality category (e.g., 50 points maximum for 5 available measures vs. 60).
  • If, however, CMS determines that additional clinical-related measures could have been submitted, the maximum number of points will remain 60.

If an individual or group submits more than 6 measures, CMS will use the “top 6” (i.e., the 6 measures with the highest individual scores) to determined the overall quality score.

The quality achievement points per measure are added together and then divided by the maximum number of quality points (i.e., 60) to get the quality performance percentage. This number is then multiplied by the category weight, 85% for PT/OT/ST in 2019, to obtain the total quality point contribution toward the final MIPS score.


A PT participating as an individual clinician reports 6 MIPS quality measures over the course of calendar year 2019 via a Qualified Registry, meeting both the data completeness (≥ 60% of all eligible patients, regardless of payer) and minimum case requirements (> 20 cases per measure):

Measure Max Quality Performance Score per Measure Clinician’s Achievement Points per Measure
128 – BMI 10 7.1
130 – Current Medications 7 (topped out with cap) 6.5
131 – Pain 10 7.0
154 – Falls Risk Assessment 7 (topped out with cap) 5.5
155 – Falls Plan of Care 7 (topped out with cap) 4.2
218 – FOTO Hip PROM 3 (no benchmark) 3


The PT in this example achieved 33.3 total points. This number is divided by the maximum achievement quality points for a PT with 6 measures available (i.e., 60) to obtain the Quality Performance Percent Score:

33.3 / 60 = 55.5%

The Quality Performance Percent Score is calculated based on the maximum number of points that an individual PT, OT or SLP clinician or group could achieve – i.e., 60 points. It is not based on the maximum number of points available for the selected measures, 44 in this example due to capped, topped out measures and a measure with no benchmark. Quality measure selection should be done carefully, considering the patient population, available measures per discipline, the reporting process (some measures are more cumbersome to capture and calculate than others), and the maximum number of points available per measure.

This quality percent score is then multiplied by the category weight to obtain the total quality point contribution toward the PT’s final MIPS score:

55.5% x 85% = 47.1 points

There are “bonus points” available in the quality category. Bonus points may be awarded for the following:

  • Small practices – 6 bonus points will be added to the numerator of the Quality performance category for small practices (≤ 15 eligible clinicians)
  • Improvement scoring – Improving quality score from one year to the next (NOTE: PTs, OTs, SLPs are not eligible for this in 2019 because they did not participate in MIPS in 2018)
  • End-to-end bonus – 1 point per quality measure for reporting quality data directly from CEHRT without any manual manipulation (NOTE: Therapy-specific EMRs do not qualify as a CEHRT and therefore, this bonus is not applicable to most PTs, OTs, and SLPs.)
  • Submitting additional outcome/high priority measures – 1 point for each additional high priority measure, 2 points for each additional outcome measure that meet data completeness and case volume requirements (NOTE: PTs and OTs who successfully report more than 6 measures and select high priority or outcomes measures (more than one FOTO measure) as their “extra” measures, would be eligible for this bonus.)

Improvement Activities

Improvement Activities are designated by CMS as either high- or medium-weighted activities. High-weighted activities are worth 20 points; medium-weighted are worth 10 points.

To receive the maximum score in this category, eligible clinicians or groups must report activities totaling 40 points: 2 high-weighted OR 1 high- and 2 medium-weighted OR 4 medium-weighted activities. Small practices (≤ 15 eligible clinicians) receive “double points” per activity and can achieve the requisite 40 points via 1 high-weighted activity or 2 medium-weighted activities.

These activities must be completed for 90 consecutive days during the performance period (i.e., calendar year 2019). The individual clinician or group must attest to completing the selected activities by submitting the attestation directly to CMS through a Qualified Registry or Qualified Clinical Data Registry with this capability or logging in to the Quality Payment Program website and attesting to activity completion. If participating as a group, one individual can log in and attest on behalf of the group.

A complete list of available Improvement Activities can be found in the Resource Center on the CMS QPP website. There are more than 100 activities to choose from, many of which are applicable to therapy providers.

Scoring is determined by dividing the total earned points for completed activities by 40 (the maximum points allows), and then multiplying by the category weight, 15%.


A PT attests to completing 30 points-worth of improvement activities during 2019. This adds 11.2 points to the total MIPS score:

30 / 40 = 75%, and then 75% x 15% = 11.2 points

Final MIPS Score

An individual clinician’s or group’s final MIPS score (between 0 and 100) is determined by adding the scores of the applicable categories together (Quality and Improvement Activities for PT/OT/ST).

In the PT example provided:

47.1 + 11.2 = 58.3 points

Since the Performance Threshold for the 2021 payment year is 30 points, this clinician would receive a positive payment adjustment (exact percentage to be determined) to all of the Medicare Part B services he/she bills in 2021.

With the 2019 performance year now underway, eligible clinicians and groups who will participate in MIPS should begin collecting Quality measure data and determining which Improvement Activities they will implement in the coming year to ensure the performance threshold is exceeded.

For more information visit:

Quality Payment Program Resource Library

2019 Medicare Physician Fee Schedule Final Rule

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Education, 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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