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2019 MIPS Toolkit

2019 MIPS Reporting Changes Due to COVID-19

The Centers for Medicare & Medicaid Services (CMS) recently announced that it made two changes pertaining to submissions for 2019 Merit-based Incentive Payment System (MIPS) data to provide relief to clinicians facing the COVID-19 pandemic.

First, the MIPS data submission deadline will be extended by 30 days to April 30, 2020. If a provider or group has already submitted MIPS data or if MIPS data is submitted by April 30, 2020, the provider or practice will be scored and will receive a MIPS payment adjustment (bonus or penalty) based on the data submitted. CMS notes that many MIPS eligible clinicians have performed very well in the MIPS program in previous years. If there is a need to revise any data that has already submitted, that can be done at qpp.cms.gov any time prior to the new deadline.

Secondly, MIPS eligible clinicians who do not submit any MIPS data by April 30, 2020 will automatically qualify for the extreme and uncontrollable circumstances policy. These clinicians will receive a neutral payment adjustment for the 2021 MIPS payment year (2019 reporting year). All four MIPS performance categories for these clinicians will be weighted at zero percent, resulting in a score equal to the performance threshold, and a neutral MIPS payment adjustment for the 2021 MIPS payment year.

However, if a MIPS eligible clinician submits data on two or more MIPS performance categories, they will be scored and receive a 2021 MIPS payment adjustment based on their 2019 MIPS final score.

The AUA notes there are several items to consider based on this announcement:

  • A provider or group who chooses not to report at this point will not be penalized. However, a bonus cannot be earned since data was not reported.
  • MIPS is a budget-neutral program, meaning that the penalties collected pay for the bonuses given. It is unclear at this point if this policy change will result in no funds available for potential bonuses.
  • Before the recent announcement, CMS announced that potential bonuses would not be larger than four percent. Participants should consider if it is worth the time and expense to report at this time for a potential bonus or would resources be better applied elsewhere by not reporting for 2019. Participants must score more than 30 points (out of 100) in order to achieve a bonus. Scores under 30 points will be penalized.
  • CMS has not determined if those who submitted data prior to the recent announcement will be penalized if they score under 30 points.

General changes to MIPS from 2018 to 2019 include:

  • Eligible clinicians (ECs) are to participate in all four components of MIPS, but the categories are not weighted equally toward the composite score.
    • Quality - 45 percent
    • Promoting Interoperability (Formerly known as Advancing Care Information) - 25 percent
    • Improvement Activities - 15 percent
    • Cost - 15 percent
  • The payment adjustment is now 7 percent. This is up from -5 percent in 2018. If an EC does not participate in MIPS, he/she will incur a 7 percent payment adjustment (penalty) on his/her Medicare Part B payments in 2021. However, there is also the potential to earn a bonus of up to +7 percent for good reporting.
  • The minimum overall score needed to avoid the penalty is now 30 points, up from 15 in 2018. Earning less than 30 points results in a negative payment adjustment, and more than 30 points ears a positive payment adjustment.
  • One must score 75 points or higher overall to be considered an "exceptional performer." (Execptional performers are entitled to an additional bonus of at least 0.5 percent in addition to the 7 percent payment adjustment.)
  • An EC is excluded from MIPS if he/she sees 200 or fewer Medicare Part B patients, performs less than 200 covered professional services, or has $90,000 or less in Part B allowed charges.
  • Even if a provider could be excluded from MIPS, he/she may have the opportunity to participate. He/she can "opt-in," meaning he/she can voluntarily participate and be subject to the payment adjustment. Another option is to voluntarily submit. The provider's data is submitted to CMS and "scored," but not subject to the payment adjustment. Voluntary reporting is like a dress rehearsal for MIPS reporting; you can find out how one would perform.
  • Multiple opportunities are available to earn bonus points, including points for those who see complex patients. See reporting categories for details.
  • There are resources and other perks available for small (15 or fewer clinicians) and/or rural practices: 
    • 6 bonus points are automatically applied to the Quality score for reporting at least 1 Quality measure.
    • Even if a small practice does not meet the data completeness requirement for Quality, 3 points will be awarded for each measure (as opposed to 1 point for all other providers).
    • Those in small practices only need to achieve 20 points in Improvement Activities (versus 40 points for other participants).
    • An exception can be requested for Promoting Interoperability.
    • Only small/rural practices are allowed to participate in Quality via claims reporting (now called Medicare Part B claims reporting).
    • Special assistance is available through CMS.

Quality Reporting

Reporting as an Individual or a Group

Providers may report as individuals where they are independently scored on the data they submit to CMS. Alternatively, they may report as a group, which CMS defines as two or more eligible clinicians (as identified by individual National Provider Identifiers or NPIs) who have reassigned their billing rights to a single Taxpayer Identification Number (TIN). The group’s score is a composite of all the clinicians’ scores. 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.

Virtual group reporting is also available, but those interested in this option must register with CMS prior to the reporting year. For more information on this option, visit CMS.gov.

Reporting Options

There are several different reporting options which may be selected to participate in the Quality Reporting program. Beginning in 2019, participants may use a combination of any of these options to complete their Quality reporting.

Medicare Part B Claims reporting (previously known as claims reporting) has traditionally been used by many urologists. However, in 2019 it may only be used by those who are members of a practice with 15 or fewer providers. It involves reporting 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. Participants must report at least 60 percent of only the Medicare Part B patients to which a measure applies.

MIPS CQM (formerly known as Qualified Registry) 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 claims data and generate reports on a provider or practice's behalf directly to the MIPS processor. Those using a Qualified Registry must report at least 60 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient). CMS annually publishes a list of approved Qualified Registries.

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. Those using a QCDR must report at least 60 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient). CMS annually publishes a list of approved QCDRs. The AUA offers its own QCDR, the AQUA Registry. For more information, contact 855-898-AQUA (2782) or AQUA@AUAnet.org.

eCOM (formerly known as Electronic Health Record) 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 EHR vendor to find out what option(s) is available to you. Both individuals and groups may use EHR reporting, and this method may allow you to qualify for bonus points in Promoting Interoperability. Those using EHR reporting must submit data for at least 60 percent of ALL the patients to which the measure(s) applies (at least one patient must be a Medicare Part B patient).

Web Interface reporting is available for groups of 25 or more clinicians who register with CMS before the deadline (usually in June). Users must report on all 10 Web Interface measures for the entire calendar year of 2019 for the first 248 eligible assigned MIPS beneficiaries. If a group does not have 248 such beneficiaries, the group must report on 100 percent of their assigned beneficiaries. For more information, see the CMS Web measures list available at qpp.cms.gov.


There are over 300 individual measures to consider for Quality reporting in 2019, and participants must report on at least 6 measures. Participants can opt to report on more than six; if that is done, CMS will use the 6 measures wit hthe highest scores. In order to help urologists find specialty specific measures, CMS created a Urology Measures Set. If you select 6 measures from this list, you do not need to report an outcome measure. However, you must select at least 1 high priority measure from the list. The AUA has also compiled a list of measures which are most applicable for urologists. If you select six measures from this list, you must report at least one outcome measure. Regardless of which measures are selected, a participant must report any measure for a minimum of 20 applicable patients. If this reporting threshold is not met, the measure will not be included in a participant's Quality scoring (unless the participant belongs to a practice with 15 or fewer providers.)

Previously the AUA recommended that participants consider the clinical conditions they treat, any practice improvement goals, work currently being done in the practice and quality information that may already be reported to other payers or entities when selecting measures. While that remains good advice, one also needs to look at possible scoring. CMS gauges how well a participant scores on a measure and assigns the participant a point total. The points for the top six reported measures are added when tallying one's Quality score.  Some measures only allow limited scoring. (See the Benchmarking section below for more details.) Therefore, participants also need to assess how well they can score on the measures they select.  

Measure Specifications and Flowcharts [pdf]

      • Measure #23 – Perioperative Care, Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) [Claims, Registry]
      • Measure #46 – Medication Reconciliation [Claims, Registry]
      • Measure #47 – Advance Care Plan [Registry]
      • Measure #48 – Urinary Incontinence, Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [Claims, Registry]
      • Measure #50 – Urinary Incontinence, Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older [Claims, Registry]
      • Measure #102 – Prostate Cancer, Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients [Registry, EHR]
      • Measure #104 – Prostate Cancer, Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients [Registry]
      • Measure #110 – Preventive Care and Screening, Influenza Immunization [ClaimsRegistry, EHR]
      • Measure #113 – Colorectal Cancer Screening [ClaimsRegistry, EHR]
      • Measure #119 – Diabetes, Medical Attention for Nephropathy [Registry, EHR]
      • Measure #128 – Preventive Care and Screening, Body Mass Index (BMI) Screening and Follow-Up [ClaimsRegistry, EHR]
      • Measure #130 – Documentation of Current Medications in the Medical Record [Claims, Registry, EHR]
      • Measure #131 – Pain Assessment and Follow-Up [Claims, Registry]
      • Measure #143 – Oncology: Medical and Radiation – Pain Intensity Quantified [Registry, EHR]
      • Measure #144 – Oncology: Medical and Radiation – Plan of Care for Pain [Registry]
      • Measure #145 – Radiology: Exposure Time Reported for Procedures Using Fluoroscopy [Claims, Registry]
      • Measure #226 – Preventive Care and Screening, Tobacco Use, Screening and Cessation Intervention [ClaimsRegistry, EHR]
      • Measure #236 – Controlling High Blood Pressure [Claims, Registry, EHR]
      • Measure #238 – Use of High-Risk Medications in the Elderly [Registry, EHR]
      • Measure #265 – Biopsy Follow-Up [Registry]
      • Measure #317 – Preventive Care and Screening, Screening for High Blood Pressure and Follow-Up Documented [ClaimsRegistry, EHR]
      • Measure #321 – CAHPS for PQRS Clinician/Group Survey
      • Measure #357 – Surgical Site Infection (SSI) [Registry]
      • Measure #358 – Patient-centered Surgical Risk Assessment and Communication [Registry]
      • Measure #374 - Closing the Referral Loop [Registry]
      • Measure #408 – Opioid Therapy Follow-up Evaluation [Registry]
      • Measure #412 – Documentation of Signed Opioid Treatment Agreement [Registry]
      • Measure #414 – Evaluation or Interview for Risk of Opioid Misuse [Registry]
      • Measure #422 – Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury [Claims, Registry]
      • Measure #428 – Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence [Registry]
      • Measure #429 – Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy [Claims, Registry]
      • Measure #431 – Preventive Care and Screening, Unhealthy Alcohol Use: Screening & Brief Counseling [Registry]
      • Measure #432 – Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
      • Measure #433 – Proportion of Patients Sustaining a Major Viscus Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
      • Measure #434 – Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair [Registry]
      • Measure #436 – Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques [ClaimsRegistry]
      • Measure #453 – Proportion Receiving Chemotherapy for the Last 14 Days of Life [Registry]
      • Measure #454 – Proportion of Patients Who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life [Registry]
      • Measure #455 – Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life [Registry]

Quality Benchmarks

Under the Quality Reporting program, participants are scored on how complete and successful their reporting is in comparison to others who are reporting. For each measure and for each reporting mechanism, a series of benchmarks have been established. CMS has created a matrix where each measure has been divided into deciles, ranging from 3 to 10. A participant will be able to use this matrix to determine into which decile his/her work falls and thus determine his/her score for that particular measure. For example, let's say a urologist is reporting Measure #130 Documentation of Current Medications in the Medical Record using Medicare Part B claims reporting. The range for this measure is:

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10






To achieve 10 points for this measure, a participant must have a perfect score, meaning he/she correctly reported on all the patients to which this measure was applicable. If he/she missed a couple of patients, his/her score would obviously decrease. For this particular measure, the participant’s score would drop down to 5 points at the maximum for anything less than perfection, but a score could be much lower because the score would need to be very close to perfection in order to get more than 3 points.

The scoring on Measure #130 is very tough because it is considered a “topped out” measure by CMS. This means that it has been widely used, and users score very well on it. CMS will begin to phase out many of the topped out measures in the coming years. CMS is trying to discourage participants from using these measures by awarding lower point values. In contrast, Measure #113 Colorectal Cancer Screening is not topped out; therefore, the ranges are wider:

Measure #113 Colorectal Cancer Screening, Claims Reporting

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10









A participant cannot score less than 3 points in 2019 for any measure reported if he/she reports on at least 60 percent of the applicable patients for those measures, but CMS may not continue this in the future. Also, if a measure is new for 2019, CMS will initially award 3 points for that measure no matter how well the participant scores. The point value may change after the reporting year ends if CMS is able to collect enough data in order to calculate a benchmark; however, there is no guarantee that will happen.

In its list of applicable measures for urologists for 2019, the AUA has assessed the benchmarks for these measures. A color code has been used to indicate scoring potential: 

No shading: Benchmarks are good for all reporting options
Orange: Benchmarks are not favorable for any reporting options
Green: Benchmarks are not available
Yellow: Benchmarks are good for CQM (registry) reporting (and many times EHR reporting)
Blue: Benchmarks are good for EHR reporting

Each measure, and its reporting mechanism, has its own unique benchmarks. So, participants will want to assess the potential benchmarks when they contemplate which measures to report. Also, reporting a measure through Medicare Part B claims reporting will have a different benchmark than reporting it through CQM (registry) reporting. Here is an example using Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older.

Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older (Medicare Part B Claims Reporting)

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10







Measure #48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older, [CQM (Registry/QCDR) Reporting]

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10









The AUA has assembled a listing of the benchmarks for the measures on its recommended list in addition to the master benchmarks list.

Quality Bonus Points

In 2019, it is possible to earn Quality bonus points. The following are bonus points applied to measure scores:

      • 2 bonus points for each additional outcome and patient experience measure*
      • 1 bonus point for each additional high-priority measure*
      • 1 bonus point per measure for using Certified Electronic Health Record Technology (CEHRT) to submit measures to a registry/QCDR or CMS (end-to-end electronic reporting)
      • 6 bonus points for those in a practice with 15 or fewer clinicians if data has been submitted for at least 1 quality measure
      • Up to 6 bonus points can be earned for improving your score (see below)

The "improvement percent score" rewards those who have improved their Quality score from the prior year. The bonus is awarded using the formula:
10% x (increase in achievement percent score for prior performace year) / (prior performance year achievement percent score)

*NOTE: The high priority and outcome measure bonus points are capped at 6 points.

Quality Reporting Program Scoring

To figure a provider's Quality reporting program score, one must determine the benchmark for each measure used. Those scores are added together along with any Quality bonus points which have been earned.  That total is divided by total available measure points (in most cases 60 points).  If an improvement percent score has been earned, it is then added to determine the final score. The score is displayed as a percentage, but a maximum score cannot exceed 100 percent. For example, if you scored perfectly on all 6 measures and achieved 10 points for each, you would have 60 divided by 60 for 100 percent. However, most people will fall below that. For example, someone's scores could be 3, 8, 7, 4, 5, and 9 = 36 points.  We'll say that a total of 8 bonus points were earned (6 since the participant is a solo practitioner and 2 more points for an additional outcome measure). This total is 44 which is then divided by 60, which comes to 73 percent.  The participant was awarded an improvement percent score of 2 percent.  So, the final Quality total is 75 percent.

The formula for determing the Quality category MIPS points is:

(Quality performance category percent score) x (Quality category weight) x 100 MIPS points

Using the example above, the score would be:

75 percent x 45 percent x 100 = 33.75 points

One should note that the Quality category weight might change for some. For example, if someone was given an exception from Promoting Interoperability, the Quality category weight becomes 70 percent (45 percent + 25 percent) in 2019. That score would then be 75 percent x 70 percent x 100 = 52.5 points.

Also, if a practice has 16 or more eligible clinicians, CMS will calculate the All-Cause Hospital Readmission measure for the claims the practice submitted for the year. The calculation is used in tallying the Quality score. Providers do not need to do any work for this calculation; it is all done by CMS.

Improvement Activities

How Are Improvement Activities Scored?

In this program, one must participate in enough activities for a minimum of 90 days to earn 40 points. All IAs are weighted either high (20 points) or medium (10 points). Participants can complete any arrangement of activities which earns 40 points. However, if a provider belongs to a practice with 15 or fewer providers, or if a provider practices in a rural or health professional shortage area, then only 20 points are needed. Participants still need to complete the activities for a minimum of 90 days. IAs account for 15 percent of the overall MIPS score.

Do I report individually or as a group?

IAs can be reported by individuals or through group reporting. Some IAs (such as participation in the Consumer Assessment of Healthcare Providers and Systems Survey-Patient Safety and Practice Assessment #11) can only be done by groups.

If a practice is using group reporting, all members of the practice earn credit for any IA completed by any member. For example, there may be five members in the practice and if one of them completes routine medication reconciliation for 90 days (Population Management #15), then all five members get credit for this activity.

How do I start?

The focus of Improvement Activities is improving the care provided to your patients, and CMS believes that focusing on specific activities for a designated time period can stimulate this care. It is important that you first do an analysis of your practice:

      • What are areas that need improvement?
      • What changes would patients most appreciate?
      • Are you currently doing improvement activities which would qualify for this program?

Then brainstorm what you can do. Hopefully, if you do need to start new or amend existing activities, you can implement something small which will not require a significant outlay of time, staffing or other resources. For example, are there programs offered through your local hospital system or through an insurance program which could satisfy an Improvement Activities requirement?

What do I choose?

There are over 100 IAs organized into eight categories:

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

The AUA has reviewed the complete list of Improvement Activities and has identified several which most urologists should be able to easily implement or adapt for their practices. These activities are highlighted in blue. However, you should review the entire list to see if there are other IAs which may be more applicable to your practice. Some practices may find that an option not selected by the AUA would be a proper fit. Additionally, several activities are highlighted in green; these can be completed through use of the AUA's Qualified Clinical Data Registry (QCDR), the AQUA Registry. If you are not yet a member of the AQUA Registry and wish to consider this reporting option, contact AQUA@AUAnet.org or 855-898-AQUA (2782) for more information. Remember you must participate in whatever activities you choose for 90 consecutive days.

Key Tips

You do not need to report or submit information to CMS as part of Improvement Activities. Rather in early 2020, CMS will require you to attest to whatever action you completed in 2019. One can attest activity completion through any comination of the following options: the CMS Quality Payment Program website, a qualified clinical data registry (QCDR), qualified registry, electronic health record system (verify your EHR has this capability), or CMS Web Interface (if there are 25 or more providers in the practice). Eligible clinicians and groups only need to attest via the Quality Payment Program website that they completed the improvement activities they selected or should work with their vendor to determine the best way to submit their activities via QCDR, a qualified registry, or their electronic health record system.

The AUA recommends that you document as much information as possible about the activities you complete. For example, if you are administering a patient satisfaction survey for 90 days, note in the patient charts who received one and when. If you attend an Institute for Healthcare Improvement event, save your registration and any materials (slides, handouts, etc.) which may have been distributed regarding the event. CMS always has the ability to audit your submissions; so, it is wise to have some kind of verification to prove what you have done. Eligible clinicians are encouraged to retain documentation for six years as required by the CMS document retention policy.

If you choose to participate in MIPS via a QCDR, you must select and achieve each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR.

Sometimes the work you will be doing will satisfy multiple Improvement Activities. You might want to consider taking advantage of this overlap.

Improvement Activity Resources

Several links and resources included in this Toolkit are available to provide more direction and guidance. It is important to note that each practice is unique, and in order to improve the care provided to patients, it is best to individualize what you will be doing as much as possible. The models and information here can serve as a basis for something that you will need to tweak slightly to make applicable to your practice.

While the AUA identified 35 activities as achievable for urologists, some will be easier than others. The following PDF provides details and resources available to help with these activities.

Note: The Quality Reporting measures listed on AUAnet.org are for the CQM (registry) option. Medicare Part B claims options are also available.


In 2019 the Cost category becomes 15 percent (up to 15 points) of a participants total MIPS score. The category shows:

      • The resources clinicians use to provide patient care
      • Medicare's expenses per beneficiary during an episode of care.  In other words, what items and services for claims are utilized by a patient in a specified timeframe for certain procedures/care.

What do I have to do? How is the Cost category figured?

The good part about the Cost category is that you do not have to do a thing. CMS uses Medicare claims data to calculate your score. However, that may also work against you. CMS attributes patients for this category, and therefore may be attributing some to urologists when they should not have done so. As a result, urologists have been penalized for not providing care for chronic conditions that are outside the scope of urology. It is important to review the yearly reports that CMS provides about the Cost category.

What Cost measures will be used in 2019?

There will be two primary measures in 2019.

1) Total per Capita Cost (TPCC) - This measures all 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, billed the most allowed charges for primary care services delivered to that patient. Depending on the providers seen/care given, patients are attributed to urologists instead of primary care providers.

2)  Medicare Spending per Beneficiary (MSPB) - The MSPB measure determines what Medicare pays for services performed by an individual clinician during an MSPB episode: the period immediately before, during, and after a patient's hospital stay. An MSPB episode includes all 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.

However, in 2019, eight additional measures have been added to the Cost category to guage specific procedural episodes. None of the eight are related to urology, but this will likely change in the future.

For more details about the Cost measures, check out the 2019 Summary of Cost Measures, Cost Measures Information Forms, and Cost Measures Code Lists.

How will I be scored?

To figure your Cost performance category score, CMS will assign a score of 1-10 points to each measure.  Secondly, they will compare your performance to other MIPS-eligible clinicians' and groups' during the performance period. 

                                                 Total Points Scored on Each Measure

 Cost Performance       =         Total Possible Points Available

If someone earned 6 points for each measure, the score would be:

(6 + 6 = 12) / (2 x 10 = 20) = 60 percent

To determine the Cost category MIPS points, the formula is:

(Cost performance category percent score) x (Cost category weight) x 100 MIPS points

For this example, that is: 60 percent x 15 percent x 100 MIPS points = 9 points

Promoting Interoperability (PI) (formerly known as Advancing Care Information)

"Know Before You Go" Information

      • In 2019, all participants must use 2015 Certified Electronic Health Record Technology (CEHRT) for a continuous 90-day period during the calendar year. If you are unsure what version of CEHRT you have, check with your EHR vendor.
      • Those in a practice with 15 or fewer providers may apply for an exception from PI.
      • In order to report for PI, participants can use one of the following methods: a qualified registry, qualified clinical data registry (QCDR), EHR, CMS Web Interface, or attestation.
      • Participants can report as an individual or a group.
      • The measures and scoring system have changed for 2019.

For more information on the exclusions and exemptions available, contact the QPP help desk at 866-288-8292 or QPP@cms.hhs.gov.

What do I do and how is my score figured?

Participants must accomplish the PI objectives by completing the related measures.

PI Objectives Chart

Participants can earn up to 110 measure points. Claiming an allowed measure exclusion causes the measure's points to be shifted to a different measure. If a clinician does not report either a numerator of 1 or a "yes" for a required non-bonus measure or claim an exclusion for it, then the entire category would receive a score of 0.  Additionally, an annual security risk analysis must be reported; if it is not, a score will not be awarded for Promoting Interoperability.

Performance points - As noted in the chart above, measures have been designated as worth up to 10, 20, or 40 points.  Performance rates are scored on a static decile scoring scale where, for instance, a performance rate of 50 percent earns 5 points out of 10, 66 percent earns 7 points out of 10 (CMS rounds 6.6 points up to 7 points), and a performance rate of less than 5 percent would receive a score of 1 if at least one patient was reported in the measure's numerator. The Public Health and Clinical Data Exchange measures are scored as yes/no.

Bonus Measure Points: Participants can earn up to 10 bonus points for reporting two optional opioid-related measures. Each measure is worth 5 points.

To calculate the PI category score, the measure points earned are divided by 100. The score is capped at 100 percent.

The formula to determine the PI category MIPS points is:

(PI performance category percent score) x (PI category weight) x 100 MIPS points

Complex Patient Bonus Points

CMS recognizes the risk factors incurred by clinicians for caring for complex patients.  Therefore, CMS will analyze participant data to determine if complex patient bonus points are appropriate. The bonus is based upon Hierarchical Condition Category (HCC) risk scores and socio-economic risk as measured based upon the proportion of patients with dual Medicare-Medicaid eligibility. Up to 5 bonus MIPS points may be awarded depending on the level of clinical complexity and risk of a clinician's patient population. The complex patient bonus will be granted only if data is submitted for at least one of the following MIPS performance categories: Quality, IA or PI; this bonus will not be granted if only the Cost category is scored.

Where can I get more information?

2019 MIPS Participation and Eligibility Fact Sheet [pdf]
2019 Cost Performance Category Fact Sheet [pdf]
2019 Cost Measure Code Lists [pdf]
2019 Cost Measure Information Forms [pdf]
2019 MIPS: Summary of Cost Measures [pdf]
2019 Promoting Interoperability Measure Specifications [pdf]
2019 Promoting Interoperability Hardship Exception Request
2019 Quality Performance Category Fact Sheet [pdf]
2019 CMS Web Interface Measure Specifications and Supporting Documents [pdf]


Quality Payment Program Help Desk
Phone: 866-288-8292

Phone: 410-689-3925
Email: quality@auanet.org