NOTE: This toolkit is for information purposes and summarizes AUA’s understanding of information from the U.S. Centers for Medicare & Medicaid Services (CMS). For official CMS wording, more detailed discussion, and/or up-to-date information on these or related topics, visit the CMS website.

This toolkit provides an overview of the 2025 participation rules, performance categories, and scoring approaches for the Traditional Merit-based Incentive Payment System (MIPS) reporting option. 

A separate MIPS Value Pathways (MVP) toolkit explains the MVP reporting option in detail and describes the three MVPs that are supported by AUA’s Quality Registry (“AQUA”) in 2025 (i.e., Advancing Cancer Care, Focusing on Women’s Health, and Optimal Care for Patients with Urologic Conditions).

The Medicare Access and CHIP Reauthorization Act of 2015— also known as MACRA—was signed into law on April 16, 2015. This law, which created the Quality Payment Program (QPP), changed the way physicians are paid for providing services under Medicare. It continued the move away from fee-for-service payment, toward value-based payment approaches that endeavor to pay clinicians based on the quality, value, and outcomes of the care they provide.

Clinicians can participate in the QPP via two separate tracks: MIPS or Advanced Alternative Payment Models (APMs).

(Source: U.S. Centers for Medicare & Medicaid Services)

With MIPS, clinicians earn payment adjustments (either bonuses or penalties) for Part B covered professional services, based on four performance categories: 

• Quality
  • This category assesses the quality of care you deliver by measuring health care processes, outcomes, and patient experiences of care.
• Cost
  • This category assesses the cost of the care you provide based on your Medicare Part B Claims.
• Improvement Activities (IA)
  • This category assesses your participation in activities that improve clinical practice and support practice engagement.
• Promoting Interoperability (PI)
  • This category assesses your promotion of patient engagement and electronic exchange of health information using certified electronic health record technology (CEHRT).

(Source: U.S. Centers for Medicare & Medicaid Services)

The 2025 MIPS performance year spans from January 1-December 31, and data collected for this timeframe must be reported to Centers for Medicare & Medicaid Services (CMS) by March 31, 2026. Payment adjustments based on 2025 performance will be made in 2027. Eligible clinicians can complete MIPS reporting for the 2025 performance year through one of three options.

• Traditional MIPS: The original reporting option for collecting and reporting data for MIPS.
• APM Performance Pathway (APP): A MIPS reporting option that is only available to clinicians participating in MIPS APMs.
• MVPs: The newest reporting option that includes a subset of measures and activities that are related to a specific specialty or medical condition. In the next few years, CMS plans to sunset Traditional MIPS and make MVP reporting mandatory for many MIPS participants.

Physicians, physician assistants, and nurse practitioners are among the types of clinicians who can participate in MIPS. The QPP Participation Status Lookup Tool, provided by CMS, allows providers to view their MIPS eligibility status.

A clinician is required to participate in MIPS (i.e., is MIPS-eligible) if he/she is an eligible clinician type and meets all of the following criteria:

• Has enrolled as a Medicare provider before January 1, 2025
• Is NOT a Qualifying Participant in an Advanced APM
• Meets all the following low-volume threshold criteria:
  • Sees more than 200 Medicare Part B patients
  • Performs 200 or more covered professional services to Part B patients
  • Has $90,000 or more in Medicare Part B covered professional services

If a clinician does not meet the eligibility requirements due to the low-volume threshold criteria, but meets at least one of those three criteria, he/she can opt-in to MIPS or voluntarily report. To opt-in, clinicians must log onto the QPP portal and register.

Those selecting this option will then be subject to applicable payment adjustments (positive or negative). In contrast, those who voluntarily report gain reporting experience, receive performance feedback, and become eligible to have performance data published on Medicare’s Care Compare. However, they are not subject to payment adjustments, and their performance results will not be included in MIPS measure benchmark calculations.

Providers may be eligible to participate in Traditional MIPS as an individual clinician, as part of a group, as part of a virtual group, or as an APM entity.

• Those reporting as an individual are scored independently on the data they submit to CMS.
• Those reporting as a group submit data on measures and activities based on the aggregated performance of clinicians who are billing under a Taxpayer Identification Number (TIN). More specifically, CMS defines a group as a single TIN with 2 or more clinicians (as identified by their National Provider Identifier (NPI), who have reassigned their Medicare billing rights to that TIN.
  • At least one clinician within the group must be MIPS-eligible.
  • The TIN’s payment adjustment will be based on the group’s final score from the MIPS performance categories.
  • If someone wishes to submit data for both individual and group reporting, CMS will analyze both sets of data and use the option with a higher score.
• Clinicians may also form virtual groups.
  • These must be approved by CMS, and those interested in participating in MIPS via this option must register with CMS prior to the reporting year.
  • More information on the virtual group option is provided on the CMS QPP website. The AQUA Registry does not support virtual groups.
• Clinicians can participate in MIPS as an APM Entity. CMS defines an APM Entity as one that participates in an Alternative Payment Model or other payer arrangement through a direct agreement with CMS or other payer, or through Federal or State law or regulation.
  • MIPS-eligible clinicians who meet specific criteria are eligible to participate in MIPS as an APM entity.
  • The performance categories are weighted differently for the APM Entity option compared with how they are weighed for the individual, group, and virtual options.
  • APM Entities must submit quality measures and improvement activities if they are reporting via the traditional MIPS or MVPs options. CMS will calculate an average score when MIPS- eligible clinicians participating in an APM Entity submit PI data as individuals or as a group. APM Entities can also report PI data at the APM Entity level.

Performance category weights vary based on the participation option.  Weights also vary for small practices that do not submit PI data or when re-weighting is applied (e.g., due to hardship exemptions or extreme and uncontrollable circumstances).

(Source: U.S. Centers for Medicare & Medicaid Services)

CMS scores each performance category separately, then adds them together to get a final score. Performance categories may be reweighted in certain circumstances (e.g., for small practices, for approved extreme and uncontrollable circumstances).

Performance Category Scoring

CMS will not combine data submitted at the individual, group, virtual group, subgroup, and/or APM Entity level into a single final score.

• Data submitted as an individual will be evaluated for all performance categories as an individual.
• Data submitted by a practice as a group will be evaluated for all performance categories as a group.
• Data submitted both as an individual or group will be evaluated as an individual and as a group for all performance categories. However, the MIPS payment adjustment will be based on the higher score.

CMS does not allow performance data to be combined between two reporting options (e.g., Traditional MIPs and an MVP) to create a single final score.   However, data for a performance category can be used across two reporting options if there is a separate submission for each option.

Performance Category Payment Impact

The performance threshold for 2025 remains 75 points.

• Participants must achieve 75 points to avoid a negative payment adjustment (penalty).
• Those who do not participate will incur a 9 percent penalty on their 2027 Part B Medicare payments, and those falling between zero and <75 points will face a penalty.
• Those scoring more than 75 points will receive a positive payment adjustment (bonus).

MIPS is a budget-neutral program, meaning the positive payment adjustments (bonuses) are funded through the negative payment adjustments (penalties). CMS no longer offers an exceptional performance bonus. 

(Source: U.S. Centers for Medicare & Medicaid Services)

The Quality performance category focuses on measures that assess health care processes, outcomes, and patient experiences of care. For this performance category, participants must report data for at least 6 quality measures (one of which must be an outcome measure, or a high-priority measure, in the absence of an applicable outcome measure) or a complete specialty measure set (if the set has less than 6 measures). Participants can opt to report on more than six measures; in that case, CMS will use the 6 measures with the highest scores. In 2025, the weight for the Quality performance category for the individual, group, and virtual group participation options is 30 percent (that is, this category accounts for 30% of the total MIPS score).

Data Collection Options

Participants may use a combination of the following five options to complete MIPS reporting for the 2025 performance year. The possible reporting options for each specific measure are listed in the measure specifications.

• A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity (such as a registry, certification board, specialty society, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. Individuals and groups may report via a QCDR. The AUA offers its own QCDR, the AQUA Registry. For more information, contact 855-898-AQUA (2782) or AQUA@AUAnet.org.
• Medicare Part B Claims reporting has traditionally been used by many urologists. However, this option may be used only by those who are members of a practice with 15 or fewer providers. This reporting option involves submitting extra Current Procedural Terminology (CPT) Category II codes (also known as Quality Data Codes or G codes) along with regular billing CPT codes and diagnosis codes on electronic or paper claims submitted to Medicare. Medicare then forwards these claims files to the
• MIPS Clinical Quality Measures (CQM) reporting may be used by both individuals and groups. It is accomplished by contracting with a CMS-approved data processing service that can compile patient data and generate reports on a provider’s or practice's behalf directly to the MIPS processor. Depending on the vendor, data can be transferred to the registry in several ways.
• Electronic Clinical Quality Measures (eCQM) reporting involves either submitting one’s data directly to CMS or to a vendor who will then submit it to CMS on the provider or practice’s behalf. Check with your electronic health record (EHR) vendor to find out what option(s) is available to you. Both individuals and groups may use EHR reporting.
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey is an optional measure for participating groups reporting through the MIPS program. The CAHPS for MIPS Survey measure is a patient experience measure; note that there are beneficiary sampling requirements for this measure. The survey must be administered by a CMS-approved vendor. Participants must register between April 1, 2025, and June 30, 2025, to administer the CAHPS for MIPS Survey measure.

Available Quality Measures

There are 195 individual measures (sometimes called “QPP measures” or “MIPS measures”) for urology care providers to consider for MIPS reporting in 2025, in addition to the 7 urology-specific measures that are available through the AQUA Registry. Of these 202 measures, 38 are CQMs and 16 are eCQMs (in some cases, AQUA supports both CQM and eCQM versions for the same measure concept).

Participants must select a minimum of Quality measures, of which, at least one must be an outcome measure or a high priority measure (if an applicable outcome measure is not available). CMS created a Urology Measure Set to assist urologists with identifying relevant measures. This measure set does not include the 7 urology-specific measures limited to use by AQUA Registry participants.

Regardless of which measures are selected, a participant must report 75 percent of the applicable patients for any measure (with a minimum of 20 applicable patients). Participants in a practice with more than 15 providers will receive a score of 0 for the measure if the reporting threshold is not met.  Participants in a practice with 15 or fewer providers will receive 3 points for the measure if the reporting threshold is not met. 

CMS gauges how well participants score on each reported measure and assigns a point total.  The AUA recommends that participants consider the following when selecting and reporting measures:

• Clinical conditions treated
• Practice improvement goals
• Current quality improvement efforts
• Quality information already being reported to other payers or entities
• Effects of measure reporting on overall MIPS score
• Need for reporting to achieve measure benchmarks

CMS will calculate a score for the Quality category based on the total points earned for the six highest-scoring measures.  Participants should consider reporting as many relevant measures as possible to ensure that CMS continues to include urology-relevant measures in the MIPS program.  

Quality Measures Supported Through the AQUA Registry

The 54 measures available through the AQUA registry are listed below. The specifications for the Non-QPP Measures and QPP Measures can be found on the AQUA Registry and CMS QPP website.

AQUA Urology Specific Measures

• AQUA8 – Hospital Admissions or Infectious Complications within 30 days of Prostate Biopsy [QCDR]
• AQUA14 – Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment [QCDR]
• AQUA15 – Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures [QCDR]
• AQUA16 – Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease [QCDR]
• AQUA35 – Non-Muscle Invasive Bladder Cancer: Initial Management/Surveillance for

Non-Muscle Invasive Bladder Cancer [QCDR]

• AQUA36 – Prostate Cancer: Confirmation Biopsy in Newly Diagnosed Patients on Active Surveillance [QCDR]
• MUSIC4 – Prostate Cancer: Active Surveillance/Watchful Waiting for Newly-Diagnosed Low-Risk Prostate Cancer Patients [QCDR]

QPP Measures

• QPP001 – Diabetes: Glycemic Status Assessment Greater Than 9% [MIPS CQM, eCQM, Claims]
• QPP047 – Advance Care Plan [MIPS CQM, Claims]
• QPP048 – Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM]
• QPP050 – Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM]
• QPP102 – Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients [MIPS CQM, eCQM]
• QPP130 – Documentation of Current Medications in the Medical Record [MIPS CQM, eCQM]
• QPP134 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan [MIPS CQM, eCQM, Claims]
• QPP143 – Oncology: Medical and Radiation – Pain Intensity Quantified [MIPS CQM, eCQM]
• QPP144 – Oncology: Medical and Radiation – Plan of Care for Pain [MIPS CQM]
• QPP226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention [MIPS CQM, eCQM, Claims]
• QPP236 – Controlling High Blood Pressure [MIPS CQM, eCQM, Claims]
• QPP238 – Use of High Risk Medication in Older Adults [MIPS CQM, eCQM]
• QPP317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented [MIPS CQM, eCQM, Claims]
• QPP318 – Falls: Screening for Future Fall Risk [eCQM]
• QPP357 – Surgical Site Infection (SSI) [MIPS CQM]
• QPP358 – Patient-Centered Surgical Risk Assessment and Communication [MIPS CQM]
• QPP370 – Depression Remission at Twelve Months [MIPS CQM, eCQM]
• QPP374 – Closing the Referral Loop: Receipt of Specialist Report [MIPS CQM, eCQM]
• QPP422 – Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury [MIPS CQM, Claims]
• QPP431 – Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling [MIPS CQM]
• QPP432 – Proportion of Patients Sustaining a Bladder or Bowel Injury at the Time of any Pelvic Organ Prolapse Repair [MIPS CQM]
• QPP453 – Percentage of Patients who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) [MIPS CQM]
• QPP457 – Percentage of Patients who Died from Cancer Admitted to Hospice for Less than 3 Days (lower score – better) [MIPS CQM]
• QPP462 – Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy [eCQM]
• QPP476 - Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia [eCQM]
• QPP481 – Intravesical Bacillus-Calmette Guerin for Non-Muscle Invasive Bladder Cancer [eCQM]
• QPP483 – Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) [MIPS CQM]
• QPP487 – Screening for Social Drivers of Health [MIPS CQM]
• QPP488 – Kidney Health Evaluation [MIPS CQM, eCQM]
• QPP490 – Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors [MIPS CQM]
• QPP493 – Adult Immunization Status [MIPS CQM]
• QPP497 – Preventive Care and Wellness (Composite) [MIPS CQM]
• QPP498 – Connection to Community Service Provider [MIPS CQM]
• QPP503 – Gains in Patient Activation Measure (PAM) Scores at 12 Months [MIPS CQM]
• QPP508 – Adult COVID-19 Vaccination Status [MIPS CQM]

Specifications for MIPS measures not supported through the AQUA registry are available in the CMS QPP Resource Library.

Automatically Calculated Quality Measures

CMS will automatically calculate four administrative claims measures for individuals, groups, and virtual groups, assuming the case minimums and clinician requirements are met. The two that are most relevant for urologists are:

• Measure ID 479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups (available for groups and virtual groups only)
• Measure ID 484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Scoring the Quality Category

MIPS participants earn points for the Quality category based on how their results compare to those of other participants.

• Measure results are compared to benchmarks based on historical data to determine the number of achievable points for submitted measures.
• Next, bonus points are awarded as applicable, and a percentage score is computed.
• Then, the final score for the Quality performance category is calculated by weighting the Quality percentage score by the Quality weight (for 2025, this is 30 percent for individuals, groups, and virtual groups).

Quality Benchmarks

Benchmarks are the point of comparison used to score submitted measures. A quality measure will be scored against a benchmark if all the following conditions are met:

• The measure meets the data completion criteria. For the 2025 performance year, it is a 75% threshold.
• The measure meets the case minimum criteria, which most often is 20 cases, and
• A benchmark exists for the measure’s collection type.

The benchmark values for MIPS and QCDR measures are available in a zipped folder located on the CMS QPP Website.  Note that the benchmark values are subject to change during the year, so clinicians should check the QPP website periodically to see if a revised version of the benchmark file has been released.

Historical Quality Benchmarks

A series of historical benchmarks has been established, when possible, for each measure, for each reporting mechanism (e.g., if a measure can be reported as a CQM and an eCQM, it will have two benchmarks). For 2025, those benchmarks were calculated using data reported for 2023.  CMS created a matrix where each measure’s results have been divided into deciles, ranging from 1 to 10.

• Typically, measures can earn between 1 and 10 achievement points if they can be scored against a benchmark.
• Participants can use this matrix to determine into which decile their performance falls, then use this information to determine the score for that measure.

Quality Measures without Historical Benchmarks

If a measure does not have a historical benchmark, CMS will attempt to calculate one using 2025 data. If no historical benchmark exists and one cannot be calculated using 2025 data, CMS will not award any points for that measure, unless the measure in its first or second year in the program. Small practices will continue to earn 3 points for reporting on measures without a benchmark.

Topped Out Quality Measures

A measure is considered “topped out” by CMS when most participants who have reported the measure have scored very well on it. CMS has begun phasing out many of the topped out measures and is trying to discourage participants from using remaining topped out measures by awarding lower point values. For some topped out measures, CMS does not award the full 10 points, even if measure results are perfect. When measures have been topped out for 2 consecutive years, for a specific collection type, the maximum number of points available is capped at 7 points.

In 2025, CMS established a topped out measure benchmarking methodology for a subset of topped out quality measures belonging to specialty sets with limited measure choice. It removes the 7-point cap for specific topped out measures by collection type, which is defined through rulemaking.  It also allows specialties impacted by limited measure choice to be scored according to defined topped out measure benchmarks. Appendix A in the Quality Benchmark User Guide contains a list of measures that will be scored according to topped out measure benchmarks. 

New Quality Measures

For a new measure in its first performance year, a minimum of 7 points will be awarded to those who successfully report on such a measure. During its second performance year, the measure will have a 5-point floor.

Quality Bonus Points and Improvement Scoring

Six bonus points will be awarded to small practices that submit data for at least one quality measure. A practice must have 15 or fewer clinicians to be considered small.

MIPS participants may be able to earn as many as 10 additional percentage points if their score for the Quality category improved compared to their score in the previous year. The bonus is awarded using the formula: 10 x (increase in achievement percent score from prior performance year / prior performance year achievement percent score).

Beginning with the 2025 performance year, CMS will apply a complex organization adjustment for APM Entities and virtual groups that report eCQMs.  One measure achievement point will be added for each submitted eCQM, assuming data completeness and case minimum requirements are met. This adjustment cannot exceed 10% of the total available Quality achievement.

Calculating the Final Score for Quality

To calculate a provider’s Quality category score:

• Use the benchmark information, for each measure, to determine the number of achievable points for that measure.
• Add those points and any bonus points earned together.
• Divide the total points by the total number of achievable measure points (in most cases, this is 60 points).
• Add the value of the improvement percent score, if it has been earned, to determine the final score.
• Display the final score as a percentage, which cannot exceed 100 percent.

If a participant scores perfectly on all 6 measures and achieves 10 points for each, that participant would receive a Quality percentage score of 100 percent (60/60 * 100%). However, most participants will not have perfect scores on each submitted measure.

Example

• A participant has the following scores for six measures: 3, 8, 6, 4, 5, and 9, for a total of 35 points, along with 6 bonus points because the participant is a solo practitioner.
  • The total number of points would be 41, which is then divided by 60 (this equals 68 percent).
  • But this participant is also awarded an improvement percent score of 2 percent. Thus, that participant’s percentage score for the Quality category is 70 percent.
• The formula for determining the total points for the Quality category is: (quality performance category percent score) x (quality category weight) x 100
• The final Quality performance category score would be 70 percent x 30 percent x 100 =21 points.

Note that the Quality category weight might change for some participants. For example, if a non-small practice is given an exception for the Promoting Interoperability performance category, the Quality category weight becomes 55 percent in 2025 (30 percent + 25 percent).

(Source: U.S. Centers for Medicare & Medicaid Services)

The measures included in the MIPS cost performance category assess the following for Medicare patients:

• Overall cost of care provided, with a focus on the primary care they received.
• Cost of services provided related to a hospital stay.
• Costs for items and services provided during specific episodes of care.

For individuals, groups, and virtual groups, the weight for the Cost performance category accounts for 30% of the total MIPS score. MIPS participants do not have to submit performance data to CMS for the Cost category. Instead, CMS uses Part A and B Medicare claims data (and, sometimes, Part D claims) to calculate participants’ Cost category score.

Population-based and Episode-based Cost Measures

There are 35 cost measures available for the 2025 performance year: two (2) that are population-based and thirty-three (33) that are episode-based. Episode-based cost measures focus on procedures, acute inpatient medical conditions and chronic conditions.  Population-based measures focus on primary and inpatient care.

The population-based cost measures for the 2025 performance year are Total Per Capita Cost (TPCC) and Medicare Spending per Beneficiary (MSPB) Clinician Measure.

• The TPCC measure assesses Medicare Part A and Part B costs during the year for attributed patients. Attribution of a given patient is based upon which clinician or group, respectively, bills allowed charges for primary care services delivered to that patient (determined by select Evaluation and Management (E/M) CPT/ Healthcare Common Procedure Coding System (HCPCS) codes). This measure is payment-standardized, risk-adjusted, and specialty-adjusted. There is a 20-case minimum for this measure. Urologists should not be attributed primary care patients; however, the AUA still recommends that providers review their annual reports to ensure that this has not
• The MSPB Clinician measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (i.e., the period immediately before, during, and after a patient’s hospital stay). An MSPB episode includes most Medicare Part A and Part B claims during the episode, specifically claims with a start date between three days before a hospital admission (the “index admission” for the episode) through 30 days after hospital discharge. The measure excludes certain services that are unlikely to be influenced by the clinician’s care decisions. Inpatient medical episodes are attributed separately from inpatient surgical episodes. The case minimum for this measure is 35 episodes.

The 33 episode-based cost measures differ from the population-based cost measures in that they include only items and services that are related to the episode of care for a specific clinical condition or procedure, as opposed to all Medicare part A and B services over a specific timeframe. The length of the episode varies, depending on the measure. Three types of episode-based cost measures have been developed:

• Procedural: These measures focus on procedures of a defined purpose or type. They assess the cost of care that’s clinically related to a specific procedure provided during an episode’s timeframe. The case minimum for these measures is 10 episodes (except the Colon and Rectal Resection measure, which has a case minimum of 20 episodes).
• Acute inpatient medical condition: These measures represent treatment for a self-limited acute illness or treatment for a flare-up or exacerbation of a condition requiring a hospital stay. They assess the cost of care clinically related to specific acute inpatient medical conditions provided during an episode’s timeframe. The case minimum for these measures is 20 episodes.
• Chronic condition: These measures assess costs for ongoing management of a long-term health condition. They assess the cost of care clinically related to the care and management of patients’ specific chronic conditions provided during a total attribution window divided into episodes. The case minimum for these measures is 20 episodes.

The two cost measures most applicable to urology are the Renal or Ureteral Stone Surgical Treatment and Prostate Cancer episode-based cost measures.

• The Renal or Ureteral Stone Surgical Treatment measure is a risk-adjusted, procedural cost measure applicable to many urologists. As a procedure measure, the case minimum is 10 episodes. The episode window for this measure spans from 90 days prior to the procedure to 30 days after.
• The Prostate Cancer episode-based cost measure is a risk-adjusted and specialty-adjusted cost measure applicable to many urologists.  As a chronic condition measure, the case minimum is 20 episodes.

Calculating the Final Score for the Cost Performance Category

For the Cost performance category, CMS will compare participants’ performance to that of other MIPS-eligible clinicians and groups during the performance period. More specifically, to calculate the score for each measure, CMS will determine the ratio of standardized observed episode costs to the expected costs and multiply that value by the average episode cost (benchmark).

For each scored measure, CMS will then assign 1-10 achievement points, based on the decile in which the score falls. The Cost performance category percent score is calculated as the total number of achievement points earned divided by the number of possible achievement points (i.e., the total number of scored measures times 10). Note that not all clinicians will qualify for all cost measures, and some may not qualify for any.  In addition, there is a maximum cost improvement score of 1 percentage point available for the Cost performance category.

Example

• A participant is scored on two cost measures (receiving 7 points for one and 9 points for the other).
  • The total number of points would be 16, which is then then divided by 20 (this equals 80 percent).
  • However, this participant did not receive an improvement point.
• The formula for determining the total points for the Quality category is: (cost performance category percent score) x (cost category weight) x 100
• The final Cost performance category score would be 80 percent x 30 percent x 100 =24 points.

(Source: U.S. Centers for Medicare & Medicaid Services)

The Improvement Activities performance category measures participation in activities that improve clinical practice, care delivery, and outcomes. Participants can select from approximately 100 activities that pertain to patient engagement, care coordination, patient safety, and other relevant areas. In 2025, the weight for the IA performance category is 15 percent for individuals, groups, and virtual groups (that is, this category accounts for 15 percent of the total MIPS score).

IAs must be implemented for at least one continuous 90-day performance period (during 2025) unless otherwise stated in the activity description. They can be reported by individuals or through group reporting. If a practice is using group reporting, at least 50 percent of the members of the practice must implement the same IA to earn credit, although they do not have to implement it at the same time.

For the 2025 performance year, improvement activities are not weighted and the number of activities required for attestation has changed.  Most clinicians must implement and submit 1 or 2 improvement activities to receive a maximum of 40 points for this category.

• One activity must be attested to by clinicians, groups, and virtual groups with the small practice, rural, non-patient facing, or health professional shortage area special status.
• Two activities must be attested to by all other clinicians, groups, and virtual groups.

All IAs must begin no later than October 3, 2025 (to have a full 90-day performance window).

Participants will attest to their IAs (note that this can be done directly or through a third party, such as the AQUA registry). Documentation supporting improvement activities is not required at the time of attestation. However, documentation should be compiled and would be required in the event of a CMS audit. Participants must keep this documentation for six years after attestation. CMS has not published the documentation requirements for 2025. However, the 2024 requirements can be a good resource in the meantime. The AUA recommends that participants document as much information as possible about the completed activities.

Examples

• If administering a patient satisfaction survey for 90 days, note in the patient charts who received one and when.
• If attending an Institute for Healthcare Improvement event, save proof of registration and any materials (slides, handouts, etc.) that may have been distributed for the event.

Getting Started with IAs

Prior to selecting IAs, practices should analyze their practices to identify:

• What areas of the practice need improvement?
• What changes would help to improve the patient’s experience?
• What existing improvement activities could satisfy the IA performance category?

Hopefully, if there is a need to begin new activities, or amend existing ones, it will not require a significant outlay of time, staffing or other resources (assuming the activity would still positively impact patient care, experience, or outcomes). For example, programs offered through a local hospital system or through an insurance program might satisfy an IA requirement.

Selecting IAs

There are approximately 100 IAs available for reporting. They are organized into eight categories, as follows:

• Achieving Health Equity (AHE)
• Behavioral and Mental Health (BMH)
• Beneficiary Engagement (BE)
• Care Coordination (CC)
• Emergency Response and Preparedness (ERP)
• Expanded Practice Access (EPA)
• Patient Safety and Practice Assessment (PSPA)
• Population Management (PM)

The AUA reviewed the IAs identified by CMS for 2025.

• Activities highlighted in blue are those that the AUA believes urologists should be able to easily implement or adapt for their practices.
• Activities highlighted in green can be completed through participation in the AQUA Registry, a QCDR.
  • Send an email to AQUA@AUAnet.org, or call 855-898-AQUA (2782) if you are interested in joining the AQUA Registry.
• Activities in light gray font were suspended by CMS on May 7, 2025.  If any of the suspended IAs have already been completed, or were in the process of being completed as of this date, clinicians will still be able to attest to completing them and receive credit.  Otherwise, clinicians should select other IAs.

When considering IAs:

• Review the full list of activities to see if there are others that may be more applicable to your practice. 
• Carefully review the CMS documentation requirements to ensure understanding and the ability to meet them.
  • If choosing to participate in MIPS via a QCDR, each improvement activity must be selected and attested to separately. Reporting for some quality measures may fulfill IA reporting requirements.
  • Selecting one activity that includes participation in a QCDR will not entitle receipt of credit for multiple IAs.
• Sometimes activities will satisfy multiple IAs, so consider taking advantage of this overlap.

Disclaimer: The AUA encourages practices to download and review CMS’ improvement activity (IA) data validation requirements. Providers should maintain documentation supporting the compilation of each activity, in the event of a future CMS audit. Additionally, the AUA and AQUA Registry cannot guarantee a positive/negative payment adjustment at any time.

IA Resources

Below, we have listed some of the available IAs. However, you should refer to CMS’s IA documentation resources for the full inventory of IAs and their associated descriptions and objectives. CMS has not published the documentation requirements for 2025. However, the 2024 requirements be a good resource in the meantime.

• IA_EPA_3: Collection and use of patient experience and satisfaction data on access
• IA_PM_16: Implementation of medication management practice improvements
• IA_CC_1: Implementation of use of specialist reports back to referring clinicians or groups to close referral loop
• IA_CC_2: Implementation of improvements that contribute to more timely communication of test results
• IA_CC_7: Regular training in care coordination
• IA_CC_12: Care coordination agreements that promote improvements in patient tracking across settings
• IA_BE_6: Regularly assess patient experience of care and follow up on findings
• IA_BE_15: Engagement of patients, family, and caregivers in developing a plan of care
• IA_PSPA_3: Participate in Institute for Healthcare Improvement (IHI) training/forum event; National Academy of Medicine, AHRQ Team STEPPS or other similar activity
• IA_PSPA_4: Administration of the AHRQ Survey on Patient Safety Culture 
• IA_PSPA_8: Use of patient safety tools
• IA_PSPA_9: Completion of the AMA STEPS Forward program

Calculating the Final Score for IAs

There are two ways to earn full credit for this category:

• One activity must be attested to by clinicians, groups, and virtual groups with the small practice, rural, non-patient facing, or health professional shortage area special status.
• Two activities must be attested to by all other clinicians, groups, and virtual groups.

Improvement activities will not be weighted beginning with 2025 performance year and the maximum number of points possible for the IA category is 40. Participants can select whatever combination of activities they desire to reach those 40 points. Again, they must engage in those activities for at least 90 continuous days, unless otherwise stated in the activity description. The IA performance category accounts for 15 percent of the overall MIPS score for individuals, groups, and virtual groups.

Example

• A participant implements 2 activities.
  • Their IA performance category percent score would be (20+20)/40=100 percent.
  • Note that a participant cannot earn more than 100% for this performance category (even if they attest to implementing additional improvement activities).

• The formula for determining the total points for the Improvement Activities category is: (IA performance category percent score) x (IA category weight) x 100.

• The final Improvement Activities performance category score would be 100 percent x 15 percent x 100 =15 points.

(Source: U.S. Centers for Medicare & Medicaid Services)

The goal of the PI performance category is to foster the electronic exchange of health information using CEHRT. Use of technology to exchange and make use of information (i.e., interoperability):

• Reduces burden associated with communicating patient information and, by extension,
• Improves patient access to their health information,
• Improves information exchange between clinicians and pharmacies, and
• Improves the systematic collection, analysis, and interpretation of healthcare data.

For 2025, the weight for the PI performance category for individuals, groups, and virtual groups is 25 percent (that is, this category accounts for 25% of the total MIPS score). The PI category focuses on 4 objectives:

• e-Prescribing
• Health Information Exchange
• Provider-to-Patient Exchange
• Public Health and Clinical Data Exchange

Participants can report either directly or through a third party, such as the AQUA Registry.  Additionally, all participants must use an EHR that meets the ONC certification criteria specified in 45 CFR 170.315 of the Code of Federal Regulations. You must collect the data for the required measures in your certified EHR technology (CEHRT) for a minimum of 180 continuous days during the calendar year.

CMS updated the minimum criteria for the 2025 performance year. A qualifying data submission includes all required performance data, required attestation statements, CEHRT ID, and the start and end date for the performance period. Reweighting can only be overridden by qualifying data submissions.

Exemptions and Exceptions

• Automatic reweighting will only apply to MIPS eligible clinicians, groups, and virtual groups, and APM Entities with the following special statuses for the 2025 performance year/2027 MIPS payment year, which means they are exempt from reporting PI data:
  • Ambulatory Surgical Center (ACS)-based
  • Hospital-based
  • Non-patient facing
  • Small practice

• Individuals, groups, and virtual groups can submit a MIPS PI Performance Category Hardship Exception application, to request exemption from reporting PI data using one of the following reasons:
  • Using decertified EHR technology
  • Having insufficient internet connectivity
  • Lacking control over CEHRT availability
  • Facing extreme and uncontrollable circumstances

• When all their MIPS-eligible clinicians are individually exempt from reporting PI data, groups, virtual groups and APM Entities qualify for automatic reweighting and are exempt from reporting PI data. If a hardship exception is approved, the PI category will receive a weight of 0% when calculating the final score.  That 25% will be redistributed to another category unless you submit data for the PI category.
  • The hardship exception results in the re-weighting of the PI category to zero. If any data are submitted for the PI category, the reweighting will be canceled, and the data will be scored. If a clinician has a reporting exemption but submits data, the data will be scored, and the exemption will be canceled.
• Those who are not automatically exempted must apply for the exception by December 31, 2025. Even if a participant received an exception previously, they must apply again in 2025.
• APM Entities reporting Traditional MIPs can choose which level to submit the PI data.  They can collect and aggregate PI data for all eligible clinicians and submit it on their behalf.  They can also have their eligible clinicians submit PI data on their own at the individual or group level. With this option, CMS will aggregate the data for the APM Entity.

Measures

For the PI performance category, participants must report on either 6 or 7 required measures. Data for these measures must be collected during the same continuous 180-day period (or more) during the calendar year.

In addition to the PI measures, participants must provide their EHR’s CMS Identification code from the Certified Health IT Product list and complete the required attestations. 

Information about the PI measures is shown below.

The specifications for the measures, and documentation requirements, are available in the CMS QPP Resource Library.

Note that the work required for all PIs must begin no later than July 5, 2025 (to have a full 180-day performance window). As with the IA performance category, documentation supporting PI reporting is not required at the time of attestation. However, documentation should be compiled and would be required in the event of a CMS audit. Participants must keep this documentation for six years after attestation.

Calculating the Final Score for Promoting Interoperability

Participants can earn a total of 100 points based on the results of the required measures.

• The total score can include 5 bonus points received for submitting a “yes” response for one of the optional Public Health and Clinical Data Exchange measures:
  • Public Health Registry Reporting
  • Clinical Data Registry Reporting
  • Syndromic Surveillance Reporting.
• A score of zero points will be earned for the PI performance category unless:
  • A participant reports at least 6 required measures (or claim their exclusions) and submits at least a “1” in the numerator for measures that require a numerator and denominator.
  • Data are collected in CEHRT with functionality that meets ONC requirements for at least 180 continuous days in 2025
  • A “yes” is submitted to the Actions to Limit or Restrict Interoperability of CEHRT Attestation (formerly named Prevention of Information Blocking)
  • A “yes” is submitted to the SAFER Guides attestation measure
  • A “yes” is submitted to the ONC Direct Review Attestation
  • A “yes” is submitted to show that a participant has completed the Security Risk Analysis measure in 2025
  • The level of active engagement for the Public Health and Clinical Data Exchange measures being reported is submitted
  • The EHR's CMS identification code from the Certified Health IT Product List (CHPL) is reported.
• Claiming an allowed measure exclusion causes that measure’s points to be shifted to a different measure.

Points for each measure are earned depending on the type of measure. Measures with a numerator and denominator receive points based on their results, which are multiplied by the maximum number of points available for the measure.

Example

The Provide Patient Electronic Access to Their Health Information measure is worth a maximum of 25 points.  A participant has a score of 75% for this measure.

• Calculate the points earned for the PI performance category (performance score x the maximum points allowed). The final point total is 19 (.75 x 25).
• Sum the points earned for each measure and divide by 100 to calculate the final percent score for the PI performance category. Note that the score is capped at 100 percent.
• The formula to determine the total points for the PI category is: (PI performance category percent score) x (PI category weight) x 100.
  • Note that the score is capped at 100 percent.

If the final percent score for the PI category is 92 percent, the final PI score would be: 92 percent x 25 percent x 100 =23 points.

(Source: U.S. Centers for Medicare & Medicaid Services)

The final MIPS score is calculated by adding together the final scores for each of the four performance categories, along with any “complex patient” bonus points earned.

Complex Patient Bonus

• CMS recognizes the challenges and costs incurred by clinicians for caring for complex patients and thus will analyze participant data to determine the number of bonus points (if any) for complex patients.
• Up to 10 bonus points will be awarded, depending on the level of clinical complexity and social risk.
  • Each provider will be evaluated individually to determine their eligibility to receive the bonus.
• The bonus is based upon Hierarchical Condition Category (HCC) risk scores that incorporate age, gender, diagnoses from the previous and whether they’re eligible for Medicaid, first qualified for Medicare because of disability, or live in an institution (to determine medical complexity) and the proportion of patients with dual Medicare-Medicaid eligibility (as a proxy for social risk).

Complex Patient Bonus Example

• The performance category scores were:
  • Quality: 21 points
  • Cost: 24 points
  • Improvement Activities: 15 points
  • Promoting Interoperability: 23 points
• Assume this participant also earned two complex patient bonus points.   
• This participant’s final MIPS score would be: 21+24+15+23+2 = 85 points.

APM Entities are only assessed and scored across 3 MIPS performance categories.

• Quality: The performance data must be aggregated for all clinicians within the APM Entity. Sometimes this aggregation must occur across multiple TINs.
• Improvement Activities: The performance data must be aggregated for all clinicians within the APM Entity. Sometimes this aggregation must occur across multiple TINs.
• Promoting Interoperability: APM Entities have two options.  They can report PI data at the APM Entity level, or they can submit the data at the group and individual level and it will be aggregated to create an APM Entity Score.

For the Cost performance category, APM Entities are not scored, regardless if reporting via traditional MIPS, the APP, or MVPs.

Most submission methods are available to APM Entities. However, only APM Entities with the small practice designation can submit Medicare Part B claims quality measures. Each MIPS-eligible clinician in the APM Entity receives a MIPS payment adjustment based on the Entity’s final score unless they have another higher score from individual or group participation.  MIPS-eligible clinicians that participate in MIPS in multiple ways under the same TIN/NPI combination will receive the highest of these final scores.

CMS has developed extensive descriptions for, and detailed documentation of, the requirements and operation of the MIPS program. Additional documents may be added, and existing documents may be updated throughout the year. These are all available on the QPP website. A few of the most helpful resources, available through this site’s Resource Library, include:

General MIPS Information

• 2025 MIPS Eligibility and Participation Quick Start Guide
• 2025 MIPS Quick Start Guide for Small Practices

Quality Performance Category

• 2025 Quality Quick Start Guide
• 2025 Quality Benchmarks User Guide

Cost Performance Category

• 2025 Cost Quick Start Guide
• 2025 MIPS Summary of Cost Measures
• 2025 MIPS Cost Measure Codes Lists

Improvement Activities Performance Category

• 2025 Improvement Activities Quick Start Guide
• 2025 Improvement Activities Inventory

Promoting Interoperability Performance Category

• 2025 Promoting Interoperability Quick Start Guide
• 2025 Promoting Interoperability Measure Specifications

You can receive additional support for, and additional information about, MIPS participation through the following sources:

CMS Quality Payment Program Help Desk

Phone: 866-288-8292
E-mail: QPP@cms.hhs.gov

AUA Quality & Measurement Department

E-mail: Quality@AUAnet.org

AQUA Registry Help Desk

E-mail: AQUA@AUAnet.org