From the Washington Office

From the Washington Office: MIPS 2018 … Determining your status, making your plan


Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.

Dr. Patrick V. Bailey, a pediatric surgeon and medical director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

Dr. Patrick V. Bailey

Approximately 622,000 of the 1.5 million clinicians billing Medicare Part B will be required to submit data under MIPS. For those clinicians not required to submit data, that exclusion will be based on their participation in an Advanced Alternative Payment Model (A-APM), their failure to meet the low-volume threshold, or the fact that they meet the criteria as a newly enrolled Medicare clinician.

If you are a Qualifying Participant (QP) in an Advanced Alternative Payment Model (APM), you are exempt from reporting MIPS data. If you are unsure of your status as such a participant, you can use you NPI number to determine your status at QPs are not only exempt from reporting MIPS data, but could receive a 5 percent bonus in 2020 for participation in 2018.

For 2018, CMS increased the low-volume threshold. The low-volume threshold is now set at less than or equal to $90,000 in Medicare Part B allowable charges or 200 or fewer Medicare Part B patients seen during the period selected by CMS. Because this threshold represents an increase compared to 2017, it will result in even more providers being exempted from participating in MIPS. It should be noted that failure to meet either of these thresholds, $90,000 in allowable charges or 200 Medicare Part B patients, is sufficient to exclude one from reporting MIPS data in 2018. As was the case in 2017, we anticipate that CMS will notify those providers who are exempt based on the low-volume threshold within the first or second quarter of 2018. Alternatively, surgeons may use their NPI to check their status relative to MIPS reporting at

To determine whether MIPS applies to your practice circumstances, you can use the following simple steps:

1) Are you a participant in a qualified advanced alternative payment model (A-APM)? If you are unsure, you can use your National Provider Identifier (NPI) number to look up your status at If you are a qualified participant in an A-APM, you are not only exempt from reporting MIPS data, but you could also receive a 5 percent bonus in 2020 for your participation in 2018.

2) Are you exempt from participating in MIPS based on the low-volume threshold? As mentioned above, for 2018, the increase in the low-volume threshold is expected to exclude a significant number of providers. To determine if you are exempt based on the low-volume threshold, use your NPI number at

3) Are your MIPS data reported for you by your institution, your employer, or your group? If your data are being reported for you then you need take no further action. You should contact your institution, employer, or group to confirm that data are being reported for you.

If MIPS applies to your practice, you need to make a choice between:

1) Submitting the minimum data necessary to avoid a penalty, and accept a freeze in your payments in 2020 for the 2018 performance period.


2) Submitting data in an effort to compete for a positive update.

If you prefer to submit the minimum amount of data necessary to avoid a penalty, your best option is to complete the requirements for the Improvement Activities (IA) component of MIPS. By achieving full credit in this category of MIPS, you will acquire enough points (15) to reach the performance threshold in your MIPS final score to avoid a 5 percent penalty in your Medicare payments in 2020 based on your performance and participation in 2018.

Within the IA category, each activity is assigned either a high (20 points) or medium (10 points) weight. To receive full credit in the IA component, most surgeons must select and attest to having completed between two and four activities for a total of 40 points in the IA category. For small practices or rural practices to achieve full credit, only one high-value or two medium-value activities are required. CMS defines small practices as those consisting of 15 or fewer eligible clinicians. The Centers for Medicare and Medicaid Services defines rural practices as those where more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s Tax Identification Number (TIN) are designated in a ZIP code as a rural area or Health Professional Shortage Area (HPSA), based on the most recent Health Resources and Services Administration Area Health Resource File data set.

Those who fulfill these requirements will receive the maximum score and full credit in the IA category toward their MIPS Final Score (15 points). Because the performance threshold for 2018 is set at 15 points, those who wish to avoid a payment penalty can acquire the required number of points to avoid a penalty for their performance in 2018 by simply fulfilling the IA requirements.

Attestation to having completed the Improvement Activities can be accomplished via a qualified registry, qualified clinical data registry (QCDR), an electronic health record (EHR), or the QPP Data Submission System (accessible at The American College of Surgeons (ACS) has two QCDRs, the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry. Both can be used to attest to completing the IAs.

If you plan to compete for a positive update in 2020 based on your performance in 2018, you should ideally report on the Quality, Advancing Care Information (ACI), and Improvement Activities categories of MIPS. If this is your intent, we recommend you obtain a copy of our new 2018 MACRA manual, visit, and make your plan for 2018.

Regardless of your choice, ACS staff in the DC office and the SSR are here to help and can be reached at 202-337-2701 (DC) or 312-202-5408 (SSR).

Until next month …

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

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