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 Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) reporting option. It also describes the three options 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).

A separate Merit-based Incentive Payment System (MIPS) toolkit explains the Traditional Merit-based Incentive Payment System (MIPS) reporting option in detail.

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: the Merit-based Incentive Payment System (MIPS) or 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 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.

The Centers for Medicare and Medicaid Services (CMS) notes that MVPs offer more meaningful groupings of measures and activities, to provide a more connected assessment of the quality of care. MVPs include the same four performance categories as Traditional MIPS (i.e., Quality, Cost, Improvement Activities, and Promoting Interoperability). However, the quality measures, cost measures, and improvement activities that are included in a particular MVP have been selected based on their alignment with the focus of the MVP (i.e., a specific condition or specialty).

• Most MVPs are limited to 10-20 quality measures, 1-3 cost measures, and 10-20 improvement activities. 
• The “foundational layer” of all MVPs includes the Promoting Interoperability performance category, where the measures and attestations are identical to those in Traditional MIPS, as well as two population health measures that CMS calculates based on administrative claims. The measures and attestations in the foundational layer are identical across all MVPs.  
• Beginning in 2025, participants no longer have to select a population health measure during the registration process. Instead, CMS will calculate both measures if the case minimum is met and use the higher score.

[Sources: U.S. Centers for Medicare & Medicaid Services; U.S. Centers for Medicare & Medicaid Services (Video)]

Voluntary MVP and subgroup reporting started in 2023. Beginning in 2026, any multispecialty groups intending to report MVPs will be required to report as subgroups or individual MIPS eligible clinicians. CMS plans to sunset Traditional MIPS in the future, at which point MVP reporting will become mandatory, unless the clinician is eligible to report via the APP.

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

There are 21 finalized MVPs available for the 2025 performance year. The AUA Quality (AQUA) Registry supports three MVPs for the 2025 performance year: Advancing Cancer Care, Focusing on Women’s Health, and Optimal Care for Patients with Urologic Conditions.

Please note, MIPS participants may report via Traditional MIPS and MVPs. If participants report via both options, CMS will calculate final scores for each and use one that is highest for payment adjustment.

As noted in the previous section, MVPs are one option for meeting MIPS reporting requirements. To report via MVP, the participant must be MIPS-eligible. CMS provides the QPP Participation Status Lookup Tool, which allows providers to view their MIPS eligibility status, including whether or not he/she is required to report. Only certain types of clinicians can participate (including physicians, physician assistants, and nurse practitioners, among others).

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 APM Participant
• 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.

Voluntary reporters, opt-in eligible clinicians, and virtual groups cannot report an MVP for the 2025 performance year. 

Options for MVP Participation

Providers may be eligible to participate in MIPS via MVPs as an individual MIPS eligible clinician, as part of a group (single specialty and multispecialty), as part of a subgroup, or as an APM entity.

• Those participating as individuals are scored independently on the data they submit to CMS.
• Those participating 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 the higher score.
• Subgroups must include at least two clinicians from the same TIN, at least one of whom must be individually eligible for MIPs.
  • A clinician can only participate in one subgroup per practice. However, if a clinician works at 2 different practices (with 2 different TINs), they can participate in a subgroup at each practice.
  • Subgroup reporting may be of interest to those in large practices or in multi-specialty groups.  As noted earlier, subgroup reporting is voluntary for 2025. However, CMS plans to require subgroup reporting for those in multispecialty groups beginning in 2026.  
• An APM Entity includes all eligible clinicians participating with an APM Entity at certain times during the year. 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 and group options.
  • APM Entities are not scored on the cost category but 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.

MVP Registration

Participants must register in advance to report an MVP. In 2025, MVP registration is open from April 1, 2025 to December 1, 2025. To report Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey as part of an MVP, participants must complete MVP registration before June 30, 2025 and must separately register to participate in the CAHPS for MIPS Survey.

After signing into the QPP Account on the QPP website using HARP credentials, participants will need to:

• Select their organization and whether they will be reporting as a group, an individual, a new subgroup, or an Alternative Payment Model (APM) Entity. 
• Identify the MVP they plan to report.
  • The selection of a population health measure is not required during the registration process.
  • MVPs can include an outcomes-based administrative claim measure. If so, participants will have to decide whether to evaluate it as 1 of the 4 required measures.

Available MVPs

The following 21 MVPs are available for reporting in 2025. The MVPs denoted with an “*” include several measures that are applicable for some urologists and are thus supported by the AQUA Registry.

• Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
• Advancing Cancer Care*
• Advancing Care for Heart Disease
• Advancing Rheumatology Patient Care
• Complete Ophthalmologic Care
• Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes
• Dermatological Care
• Focusing on Women’s Health*
• Gastroenterology Care
• Improving Care for Lower Extremity Joint Repair
• Optimal Care for Kidney Health
• Optimal Care for Patients with Urologic Conditions*
• Patient Safety and Support of Positive Experiences with Anesthesia
• Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV
• Pulmonology Care
• Quality Care for Patients with Neurological Conditions
• Quality Care for the Treatment of Ear, Nose, and Throat Disorders
• Quality Care in Mental Health and Substance Use Disorders
• Rehabilitative Support for Musculoskeletal Care
• Surgical Care
• Value in Primary Care

As noted earlier, the basic scoring categories for MIPS and MVPs are similar, although the performance categories are structured somewhat differently.

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

• Participants are required to report 4 quality measures from an MVP, one of which must be an outcome measure.  If an outcome measure is not available, a high priority measure must be reported.
• One Population Health Measure, included in the “Foundational Layer”, is calculated via administrative claims and is included in the final “Quality” scoring. CMS will calculate all available population health measures and use the highest score.
• Performance categories may be re-weighted from the above values in certain circumstances (e.g., for small practices, for approved extreme and uncontrollable circumstances, etc.).

The PI Performance Category for small practices and APM Entities with a small practice status accounts 0% of the final MVP score because the promoting interoperability is automatically reweighted.

Performance Category Scoring

Clinicians reporting an MVP will receive feedback comparing their performance in each category to other clinicians reporting the same MVP. However, clinicians reporting an MVP will not be scored solely in comparison to the other clinicians reporting that MVP.

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 CMS determines the positive payment adjustments (bonuses) based on the negative payment adjustments (penalties). 

(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. There are two components to this performance category:

• Participants must report data for at least 4 quality measures from the MVP (one of which must be an outcome measure, or a high-priority measure, in the absence of an applicable outcome measure). Participants can opt to report on more than four measures; in that case, CMS will use the four measures with the highest scores.
• The Population Health Measure (included in the “Foundational Layer”) is calculated via administrative claims. CMS will calculate all available population health measures and use the highest score.

Measures that do not meet case minimum or data completeness criteria will earn zero points.  In 2025, the weight for the Quality performance category is 30 percent for individuals, groups, and subgroups (that is, this category accounts for 30% of the total MIPS score).

Data Collection Options

There are several different ways that measures can be collected and reported for MIPS. In 2025, participants may use a combination of any of these options to complete their MIPS reporting. 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. Please note that the AQUA Registry may not support a QCDR measure included in a supported MVP.
• Medicare Part B Claims reporting may be used only by those who are members of a practice with 15 or fewer providers. This reporting option involves submitting extra 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 processor. To meet data completeness requirements, practices will need to start reporting the Medicare Part B claims measures in their selected MVP in January 2025, prior to the MVP registration period.
• 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 a number of 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.
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey is an optional measure for participating groups, subgroups, and APM entities reporting through the MIPS program. If the CAHPS for MIPS Survey is available within your selected MVP, it can be reported as 1 of the 4 required quality measures. 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 report on the CAHPS for MIPS Survey measure.

Quality Measures in MVPs Supported by AQUA

For 2025, the AQUA Registry supports three MVPs (Advancing Cancer Care, Focusing on Women’s Health, and Optimal Care for Patients with Urologic Conditions).  However, the AQUA Registry may not support all the quality measures in each MVP.

Advancing Cancer Care: Quality Measures

The Advancing Cancer Care MVP focuses on the clinical theme of providing fundamental treatment and management of cancer care. The measures assess three critical areas: the patient experience of care, end of life care, and appropriate diagnostics along with possible treatment options for different cancer diagnoses. Measures in bold font are supported in the AQUA Registry.

• QPP047: Advance Care Plan [MIPS CQM, Claims]^!†
• QPP102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients [eCQM, MIPS CQM] ^!
• QPP134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan [eCQM, MIPS CQM, Claims]^†
• QPP143: Oncology: Medical and Radiation - Pain Intensity Quantified [eCQM, MIPS CQM]^!
• QPP144: Oncology: Medical and Radiation - Plan of Care for Pain [MIPS CQM]^!
• QPP321: CAHPS for MIPS Clinician/Group Survey^!
• QPP450: Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer [MIPS CQM]^!
• QPP451: RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy [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]
• QPP487: Screening for Social Drivers of Health [MIPS CQM]^!
• QPP490: Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors [MIPS CQM]
• QPP495: Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood [MIPS CQM]^!
• QPP503: Gains in Patient Activation Measure (PAM) Scores at 12 Months [MIPS CQM]^!
• QPP506: Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy [MIPS CQM]^!
• QPP507: Appropriate Germline Testing for Ovarian Cancer Patients [MIPS CQM]
• PIMSH13: Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy [QCDR]^!
• PIMSH17: Oncology: Utilization of Prophylactic GCSF for Cancer Patients Receiving Low-Risk Chemotherapy (inverse measure) [QCDR]^!

^! This is a high priority measure.

 ^†If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don't need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.

Focusing on Women’s Health: Quality Measures

Focusing on Women’s Health MVP focuses on the clinical theme of providing treatment and management of women’s health. Measures in bold font are supported in the AQUA Registry.

• QPP039: Screening for Osteoporosis for Women Aged 65-85 Years of Age [MIPS CQM, Claims]
• QPP048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM]
• QPP112: Breast Cancer Screening [eCQM, MIPS CQM, Claims]
• QPP134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan [eCQM, MIPS CQM, Claims]
• QPP226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention [eCQM, MIPS CQM, Claims]
• QPP309: Cervical Cancer Screening [eCQM]
• QPP310: Chlamydia Screening for Women [eCQM]
• QPP335: Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) [MIPS CQM]^!
• QPP336: Maternity Care: Postpartum Follow-up and Care Coordination [MIPS CQM]^!
• QPP400: One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation [MIPS CQM]
• 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 Injury at the Time of any Pelvic Organ Prolapse Repair [MIPS CQM]^!
• QPP448: Appropriate Workup Prior to Endometrial Ablation [MIPS CQM]^!
• QPP475: HIV Screening [eCQM]
• QPP487: Screening for Social Drivers of Health [MIPS CQM]^!
• QPP493: Adult Immunization Status [MIPS CQM]
• QPP496: Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument [MIPS CQM]
• UREQA8: Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved [QCDR]^!

^! This is a high priority measure.

Optimal Care for Patients with Urologic Conditions: Quality Measures

The Optimal Care for Patients with Urologic Conditions MVP focuses on assessing optimal care for patients treated for a broad range of urologic conditions, including kidney stones, urinary incontinence, bladder cancer, and prostate cancer. Measures in bold font are supported in the AQUA Registry.

• QPP050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM]^!
• QPP318: Falls: Screening for Future Fall Risk [eCQM]^!
• QPP321: CAHPS for MIPS Clinician/Group Survey^!
• QPP358: Patient-Centered Surgical Risk Assessment and Communication [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]^!
• QPP487: Screening for Social Drivers of Health [MIPS CQM]^!
• QPP503: Gains in Patient Activation Measure (PAM) Scores at 12 Months [MIPS CQM]^!
• 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]
• MUSIC4: Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients [QCDR]^!

^! This is a high priority measure.

Population Health Measures

Beginning with the 2025 performance year, participants will not be required to select a population health measure during MVP registration.

• CMS will calculate both population health measures (if the participant meets the case minimum) but will only assign the higher of these measures to the quality score.
• Participants do not have to submit any data for this measure, as CMS will calculate population health measures using administrative claims data.
• The population health measure does not count as one of the required 4 quality measures, but it will be included in the final score for the quality performance category.
• Participants can earn between 1 and 10 points for their selected population health measure based on comparison to a performance period benchmark.

If the MVP participant doesn’t meet the case minimum for either population health measure, the measure will be excluded from scoring.

• Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups (available for groups only – subgroups will be evaluated at the affiliated group level):
  • The Hospital-wide, 30-Day, All-cause Unplanned Readmission (HWR) rate for the Merit-based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for Medicare Fee-for-Service (FFS) beneficiaries aged 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge.
  • The measure attributes readmissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s readmission rate.
• Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
  • The measure is an annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions.
  • The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors.
  • The measure attributes admissions to MIPS participating clinicians or clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN), or to Accountable Care Organizations (ACOs), as identified by an aggregate of TINs that participate in these ACOs.
  • The measure is calculated for MIPS TINs/ACOs with at least 16 clinicians per group and a case minimum of at least 18 patients with MCCs. Lower measure scores indicate better performance.

Scoring the Quality Category

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

• Measure results are compared to benchmarks based on historical data to determine the number of achievable points for submitted quality measures and the population health measure.
• 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 subgroups).

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.
• A benchmark exists for the measure’s collection type.

For each measure, for each reporting mechanism, a series of historical benchmarks has been established if possible. The benchmarks calculated for the 2025 performance year were calculated based on data submitted for 2023. CMS created a matrix where each measure’s results have been divided into deciles, ranging from 1 to 10.

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

If a measure is considered “topped out” by CMS, this means 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.

Each measure, and its reporting mechanism, has its own unique benchmarks.

• For example, a measure collected through Medicare Part B claims may have a different benchmark than if collected through a CQM or eCQM. Thus, participants will want to assess the potential benchmarks when they contemplate which measures to report.
• Measures, whether reporting via MVPs, MIPS, or APPs will be scored against the same benchmark identified in the 2025 Quality Benchmarks file (or calculated based on performance period data) for their selected collection type.

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, for most participants, CMS will not award any points for that measure.
• However, small practices will earn 3 points for reporting on measures without a benchmark.
• For a new measure in its first performance year, a minimum of 7 points will be awarded for those who successfully report on such a measure. During its second performance year, the measure will have a 5-point floor.

The benchmark values for measures are available in a comma-delimited file 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.

Quality Bonus Points and Quality Improvement Scoring

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

Bonus points are available for small practices only. For those in a practice with 15 or fewer clinicians who submit data for at least one quality measure, six bonus points will be awarded.

MVP 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.

• If an MVP participant reported via Traditional MIPS the prior performance year, CMS will use that achievement score to calculate the improvement score for the current performance 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).

According to CMS, one measure achievement point will be added for each submitted eCQM that meets data completeness and case minimum requirements for APM Entities reporting an MVP. The adjustment may not exceed 10% of the total available measure achievement points in the quality performance category.

Quality Improvement Score Example

• A participant has a 2025 score of 80% and a 2024 score of 67%.
• Subtract the 2024 score from the 2025 score (80-67 = 13).
• Divide the difference by the 2024 score (13 /67=.194).
• Multiple the final number by 10% (.194 x 10).
• The Improvement percent score (rounded) will be 1.9%.

Calculating the Final Score for the Quality Performance Category

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. (Recall that if more than 4 measures have been reported, CMS will use those with the highest scores.)
• 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 50 points – 40 points from the quality measures and 10 points from the population health measure).
• 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.

Calculating the Final Score for Quality Example: Individuals, Groups, and APM Entities (Not Part of a Small Practice)

• A participant has the following scores for four measures: 8.5, 7.9, 7.2, and 8.2, for a total of 31.8 points) and 7.1 points for the population health measure.
• The total number of points would be 38.9, which is then then divided by 50 (this equals 77.8 percent). But this participant is also awarded an improvement percent score of 4.21 percent.
• The participant’s percentage score for the Quality category is 82 percent.

Using the example above, the Quality performance category score would be: 82 percent x 30 percent x 100 =24.6 points.

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

Calculating the Final Score Quality Example: Individuals, Groups, and APM Entities (Part of a Small Practice)

• A participant has the following scores for four measures: 8.5, 7.9, 7.2, and 8.2, for a total of 31.8 points) and 7.1 points for the population health measure.
• Six points are added because the participant is part of a small practice.
• The total number of points would be 44.9, which is then then divided by 50 (this equals 89.8 percent). But this participant is also awarded an improvement percent score of 4.21 percent.
• The participant’s percentage score for the Quality category is 94 percent (rounded).
• Using the example above, the Quality performance category score would be: 82 percent x 30 percent x 100 =24.6 points.

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

Note that the Quality category weight might change for some participants. For example, small practices are not required to report on the Promoting Interoperability category. 

• If small practices do not submit data for this category, the Quality category weight becomes 40 percent in 2025.
• For MVPs, the Quality performance category will not be reweighted if CMS cannot calculate a score for the MIPS eligible clinician because there isn’t at least one quality measure applicable and available to the clinician.

(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.

In 2025, the weight for the Cost performance category remains 30 percent for individuals, groups, and subgroups (that is, this category accounts for 30% of the total MIPS score).

Participants do not select cost measures during MVP registration.

• CMS will calculate the performance on all the cost measures included in the MVP based on available Medicare claims data.
• Participants do not need to submit data for the Cost performance category.
• Participants will only be scored on the MVP cost measures in the MVP for which they meet or exceed the established case minimum.

Cost Measures in MVPs Supported by AQUA

Advancing Cancer Care: Cost Measures

• COST_PC_1: Prostate Cancer Episode-based Cost Measure
  • The Prostate Cancer episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat prostate cancer.
  • This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Prostate Cancer episode.
• TPCC_1: Total Per Capita Cost (TPCC)
  • The TPCC measures the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s).
  • The measure is a payment-standardized, risk-adjusted, and specialty-adjusted measure.

Focusing on Women’s Health: Cost Measures

• MSPB_1: Medicare Spending Per Beneficiary (MSPB) Clinician
  • The MSPB Clinician measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (hereafter referred to as the “episode”), which comprises the period immediately prior to, during, and following the patient’s hospital stay.
  • An episode includes Medicare Part A and Part B claims with a start date between 3 days prior to a hospital admission (also known as the “index admission” for the episode) through 30 days after hospital discharge, excluding a defined list of services that are unlikely to be influenced by the clinician’s care decisions and are, thus, considered unrelated to the index admission.
• TPCC_1: Total Per Capita Cost (TPCC)
  • The TPCC measures the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s).
  • The measure is a payment-standardized, risk-adjusted, and specialty-adjusted measure.

Optimal Care for Patients with Urologic Conditions: Cost Measures

• COST_RUSST_1: Renal or Ureteral Stone Surgical Treatment
  • The Renal or Ureteral Stone Surgical Treatment episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive surgical treatment for renal or ureteral stones during the performance period.
  • The measure score is the clinician’s risk adjusted cost for the episode group averaged across all episodes attributed to the clinician.
  • This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 90 days prior to the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
• MSPB_1: Medicare Spending Per Beneficiary (MSPB) Clinician
  • The MSPB Clinician measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (hereafter referred to as the “episode”), which comprises the period immediately prior to, during, and following the patient’s hospital stay.
  • An episode includes Medicare Part A and Part B claims with a start date between 3 days prior to a hospital admission (also known as the “index admission” for the episode) through 30 days after hospital discharge, excluding a defined list of services that are unlikely to be influenced by the clinician’s care decisions and are, thus, considered unrelated to the index admission.
• COST_PC_1: Prostate Cancer Episode-based Cost Measure
  • The Prostate Cancer episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat prostate cancer.
  • This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Prostate Cancer episode.

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). There is a single benchmark for scoring each cost measure, whether it is being scored as part of an MVP or traditional MIPS.

For each scored measure, CMS will then assign 1-10 achievement points, based on the decile in which the score falls based on standard deviation, median, and an achievement point value that is derived from the performance threshold. For example, a clinician with costs equal to the median cost for a measure will receive 7.5 achievement points.

The Cost performance category percent score is calculated based on the points earned for scored measures, total available measure points, and the improvement score. 

Improvement Score Example

• A participant has a 70% cost score in 2025 and a cost score of 60% in 2024. 
  • The 2024 cost score is subtracted from the 2025 score (70%-60%=10%).
• The difference between the two scores (10%) is divided by the 2024 score (60%).
• The final score is then multiplied by 100 resulting in an improvement score of 0.17% ([(10/60 x 100)].

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

Final Score Example

• A participant is scored on two cost measures worth 10 points each (6.8 and 6.1 points) and has an improvement score of .21%.
• The total points earned is 12.9 (6.8 + 6.1), which will be divided by the total points available (20). 
• The total is multiplied by 100, resulting in a score of 64.5%. This score is then added to the improvement score (.21%)
• The Cost performance category percent score will be ((6.8+6.1)/20)*100=64.5% +0.21%= 64.71%.

Using the example above, the Cost score would be: 64.71% x 30% (performance weight) x 100 = 19.41 points (out of 30 points).

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

The Improvement score is based on the previous cost score and the current cost score. There is a maximum improvement score of 1 percentage point available for the Cost performance category. If cost performance decreases, the improvement score will be 0.

(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 Improvement Activities

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 Improvement Activities

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 of 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 Improvement Activities

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)

(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
• Improves patient access to their health information
• Improves information exchange between clinicians and pharmacies
• Improves the systematic collection, analysis, and interpretation of healthcare data.

The PI category is included in the “Foundational Layer” of the MVP, meaning that the PI measures are the same for every MVP.  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.  Participants must collect the data for the required measures via certified EHR technology (CEHRT) for a minimum of 180 continuous days during the calendar year.

Exemptions and Exceptions

• Automatic reweighting will only apply to MIPS eligible clinicians, 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 and 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, 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 is 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.

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.

Additional information about the PI measures is shown below.

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

The specifications for the measures are posted on 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.

Data Submission

Participants cannot combine performance data submitted between different reporting options (e.g., traditional MIPS and MVPs) into a single final score or submit performance data for one performance category and count it for both reporting options. For example, PI data cannot be reported for traditional MIPS and count towards the PI category for an MVP. More specifically, although the PI data may be the same, there must be two separate submissions:

• One for traditional MIPS and
• One for MVP reporting (with the appropriate MVP identifier, and subgroup identifier if applicable).

In addition, each MVP submission must include the related MVP ID, signaling the participant’s intent to report the PI data for their selected MVP.  Any data submitted without the necessary MVP ID will be attributed to traditional MIPS instead of the MVP.

• If the participant is reporting an MVP as a subgroup, they will submit their affiliated group’s data for the PI performance category.
• If the participant is reporting as an APM Entity, they may choose to report data for the PI performance category at the individual, group, or APM Entity level.
• When reporting at the individual and/or group level by the MIPS eligible clinicians in the APM Entity, the APM Entity will receive a score based on the weighted average of the data submitted.

Calculating the Final Score for the Promoting Interoperability Performance Category

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

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 is 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%.

• 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.

An MVP participant will receive a final score based on the same performance category weights used in traditional MIPS, and the same performance category weight redistribution policies apply. 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).

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.

Example

CMS has provided the following example for how the final MVP score is calculated.

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

CMS has developed extensive descriptions for, and detailed documentation of, the requirements and operation of the MIPS program and MVPs. These are available on its QPP website. A few of the most helpful resources, available through this site’s Resource Library, include:

General MIPS Information

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

General MVP Information

• 2025 MVP Implementation Guide
• 2025 MVP Registration Guide

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