Frequently Asked Questions

What is MIPS?

The Merit-based Incentive Payment System (MIPS) is a program developed by the Centers for Medicare and Medicaid Services (CMS) to promote higher quality of care and reduced costs. All Clinicians who bill Medicare must participate in the Quality Payment Program (QPP) or face penalties. Unfortunately, there are few opportunities for hospital-based clinicians to participate in QPP Advanced Payment Models (APMs) currently. Thus, the vast majority of acute care clinicians participate in MIPS.

How does MIPS affect clinician reimbursement?

Currently, MIPS carries up to a 9% risk relative to Medicare payments. This means that clinicians with the lowest performance will receive a 9% reduction from their Medicare payments. Since 2022, all clinicians and groups scoring below 75/100 in MIPS incur a penalty, but the penalty amount decreases as the score approaches the 75 point threshold.

For clinicians with high MIPS performance scores (>75), there is potential for positive payment adjustments, or bonuses. MIPS is a budget neutral program, meaning that CMS redistributes funds deducted from low performers to reward the high performers.

How is the MIPS score determined?

The MIPS total score is determined by performance on 4 categories, each of which is individually weighted and scored.

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Category	Details	2025 Weight
Quality	4-6 measures Max score: 70 pts	30% (85% if no PI or Cost)
Improvement Activities	Attestations submitted annually on improvement activities Max score: 40 pts	15%
Promoting Interoperability (PI)	EHR related, hospital-based physicians are exempt	25%(redistributed to Quality)
Cost	Calculated by CMS, based on claims	30% (if N/A, redistributed to Quality)

The Cost category assesses costs of care to Medicare beneficiaries. Currently, the measures used in this category may or may not apply to you/your Group. Only CMS identifies performance and scoring in this category after the performance year has concluded.

What is a QCDR?

A Qualified Clinical Data Registry (QCDR) is a reporting platform authorized by CMS. It allows vendors to report data from each of the categories of MIPS to CMS on behalf of clinicians. Clinical Performance Registry is a vendor/owner of two QCDRs:

Emergency Clinical Performance Registry (E-CPR)for emergency medicine and urgent care.
Hospitalist-Clinical Performance Registry (H-CPR) for inpatient medicine, like hospitalists, intensivists, post-acute care, and more.

Does CMS give clinicians an individual performance score?

MIPS data can be reported to CMS in many ways. Current reporting options include:

Individually: at the individual NPI-level, each NPI may have a separate score.
Group: aggregated at a Tax ID (TIN)-level, where individuals are aggregated into one score. May include multiple practice locations or specialties.
Subgroup: breakdown of TIN-level to specific specialties or geographic locations.
Virtual Group: combination of 2 or more TINs.

As a MIPS eligible clinician or group not participating in an Alternate Payment Model (APM), you can also elect to report by Traditional MIPS or MIPS Value Pathway (MVP). MVPs are subset of measures and activities based on clinical specialty, where then only 4 quality measures are required, compared to Traditional MIPS where 6 quality measures are required.

How do we choose how and what to report?

CMS’s Quality Payment Program website (https://qpp.cms.gov/) is the source of truth for eligibility, see the individual Participant status look-up on the homepage. To view Group eligibility, you will need an active account with CMS.

Strategizing measure selection is based on your patient population, areas for improvement, clinical priorities, benchmarking of relevant measures, and available MVPs.

Clinical Performance Registry can help with this, as requested.

How do we get quality measure data?

Most often, quality measures are abstracted by coders within revenue cycle management (RCM). The coders identify quality measure inclusion via ICD-10 and CPT codes. The coders then follow a scoring algorithm to determine if the measure criteria are met or not by the provider’s documentation.

Becoming more common, quality measures can be abstracted electronically from EHRs, billing data feeds and/or AI-powered chart abstraction. Digital processes will then review discrete fields to follow the scoring algorithm.

Clinical Performance Registry takes this measure data and aggregates based on your selected MIPS strategy to report to CMS.

How do we know that the data is accurate?

Clinical Performance Registry works with you to implement a data validation plan to ensure and continually verify that performance data is accurate to source clinical documentation. As a CMS-approved vendor, minimum requirements include sampling a certain amount of reporters and certain percentage of cases.

Which measures are available?

The current measures reported via our QCDRs can be found:

E-CPR
H-CPR

How can Clinical Performance Registry help me improve and avoid penalties?

Our team has available documentation tip guides, best practice toolkits, and algorithms that can help you and your group improve performance on quality measures.

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Our QCDR program offers a proven approach that simplifies the reporting process and allows clinicians to focus on patient care.