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Collection period for MIPS 2021 started on January 1st, 2021 and will end on December 31, 2021. By March 31 2022, eligible clinicians need to submit MIPS 2021 data for the Centers for Medicare and Medicaid Quality Payment Program (CMS QPP). 2021 data directly impacts the physician fee schedule payments for the year of 2023. 

This blog post summarizes some of these changes and provides an overview on how WoundReference can support eligible clinicians and groups participating in MIPS. For more information on MIPS Improvement Activities see topic "MIPS in Wound Care and Hyperbaric Medicine - Improvement Activities"For an update on Quality in wound care see topic "Quality in Wound Care".

What is MIPS ?

CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program (QPP), which rewards value and outcomes in one of two ways: 

  • Merit-based Incentive Payment System (MIPS) >> Continue reading for more information
  • Advanced Alternative Payment Models (APMs). For more information on APMs visit the QPP website

Under MIPS, eligible clinicians are required to submit data across 4 categories (Quality, Promoting Interoperability, Improvement Activities and Cost). A final score (0-100) is calculated from these 4 categories. Each eligible clinician or group’s final score is compared to a performance threshold. Final scores above the threshold receive a positive payment adjustment (bonus). 

Some MIPS categories require data to be collected throughout the entire year of 2021.

However, if you have not started collecting data for 2021 yet, it is not too late to start now. Submitting some data is better than submitting no data.

How does MIPS affect payments to eligible clinicians? 

If you are required to participate in MIPS, you will earn a performance-based payment adjustment - up, down, or not at all - based on the 2021 data that you submit (or do not submit) by March 2022. Payment of 2023 will be affected.

If you don’t submit any 2021 data by March 2022, then you receive a negative 9% payment adjustment in 2023. So for data collected in 2021, every $1 million that would be received from Medicare for services provided in 2021, you could lose $90,000.

How do I know if I am required to participate in MIPS? 

Clinicians listed in table 1 who bill Medicare through the Medicare Physician Fee Schedule and meet certain criteria are required to participate:

Table 1. MIPS 2021 - Eligible Clinician Types
  • Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
  • Osteopathic practitioners
  • Chiropractors
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians or nutrition professionals

For eligible clinician types above, the quickest way to find out if a clinician meets participation criteria is by looking him/her up on the QPP Participation Status Tool. 

  • You will need your National Provider Identifier (NPI) and Associated Taxpayer Identification Numbers (TINs). When you reassign your Medicare billing rights to a TIN (e.g., TIN that belongs to a hospital or practice), your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination. 
  • If the provider is required to participate, determine if provider is considered “Facility-based”. Medicare's goal for measuring performance at the facility level is to reduce reporting burden for MIPS eligible clinicians who are facility-based.
  • See Medicare's '2021 MIPS Eligibility Decision Tree'.

How can I participate in MIPS 2021? 

"Participation options" refers to the levels at which data can be collected and submitted, or "reported", to CMS for MIPS. There are 4 participation option for MIPS eligible clinicians: 1. as an individual, 2. group, 3. virtual group, or 4. as an alternative payment model (APM) Entity.  

  • To participate as an individual, clinician needs to:
    • Be identified as a MIPS eligible clinician type on Medicare Part B claims, (see Table 1),
    • Have enrolled as a Medicare provider before 2021, 
    • Not be a Qualifying Alternative Payment Model Participant (QP), AND
    • Exceed the low volume threshold as an individual
      • What is the low volume threshold? Medicare looks at your Medicare claims from two 12-month segments, referred to as the MIPS determination period, to assess the volume of care you provide to Medicare beneficiaries. Data from the first segment is released as preliminary eligibility. Data from the second segment is reconciled with the first segment and released as the final eligibility determination. The two 12-month segments for MIPS 2021 are: October 1, 2019 – September 30, 2020 and October 1, 2020 – September 30, 2021. Medicare will release final (reconciled) data from the 2 segments in November 2021.  Medicare will notify you when your new eligibility information is posted on the QPP Participation Status Lookup Tool
      • You must participate in MIPS if, in both 12-month segments, you:
        • Bill more than $90,000 for Part B covered professional services/ segment AND
        • See more than 200 Part B patients/ segment AND
        • Provide 200 or more covered professional services to Part B patients.
      • If you start billing Medicare Part B claims under a practice’s TIN during segment 2, your eligibility at that practice will be based solely on the results from segment 2.
  • If you’re not required to participate as an individual, you may still be required to participate (and receive a payment adjustment) if:
    • Your practice chooses to participate as a group
    • You are part of an approved virtual group
    • You participate in a type of APM called a MIPS APM

Which reporting framework should I follow to collect and submit data? 

There are three MIPS reporting frameworks available to MIPS eligible clinicians:

  • Traditional MIPS, established in the first year of the Quality Payment Program, is the original framework for reporting to MIPS. You select the quality measures and improvement activities, in addition to the complete Promoting Interoperability measure set, that you will collect and report. Medicare collects and calculates data for the Cost performance category for you.
  • The Alternative Payment Model (APM) Performance Pathway, or APP, is a streamlined reporting framework beginning with the 2021 performance period for clinicians who participate in a MIPS APM. The APP is designed to reduce reporting burden, create new scoring opportunities for participants in MIPS APMs, and encourage participation in APMs. 
  • MIPS Value Pathways, or MVPs, are a reporting framework that will offer clinicians a subset of measures and activities, established through rulemaking, that are relevant to a specialty, medical condition, or episode of care. MVPs are tied to our goal of moving away from siloed reporting of measures and activities towards focused sets of measures and activities that are more meaningful to a clinician’s practice, specialty, or public health priority.  We finalized 7 MVPs in the CY 2022  Physician Fee Schedule Final Rule for reporting to begin with the 2023 performance year.

How do I get started?

Follow this Medicare checklist:

  1. Determine eligibility for QPP (Now): Check if you are required to participate by using the QPP Participation Status Tool.
  2. If participation is required, determine if you’re participating in MIPS as an individual, group, virtual group, and/or APM Entity (Now)
  3. Determine how you'll report (see above): traditional MIPS or APP (Now)
  4. Review the current performance year’s quality measures (Now). Collect and perform your measure and activities (throughout 2021). For Quality, clinicians must collect data for each measure from January 1 to December 31, 2021. Plan to collect at least 90 days of data for the other performance categories. You don’t have to collect cost data, Medicare collects cost data on your behalf 
    1. Traditional MIPS: Quality, Promoting Interoperability, Improvement Activities, Cost
    2. APP: Quality, Promoting Interoperability, Improvement Activities
  5. Verify your eligibility (late 2021)
  6. Submit your data (early 2022)
  7. Review your feedback (mid 2022)
  8. Preview your data for public reporting (late 2022 or early 2023)
  9. Note the application of payment adjustments (throughout 2023)

Table 2. Summary of traditional MIPS 2021 - categories, submission requirements and collection period  

QualityPromoting InteroperabilityImprovement ActivitiesCost
Percentage of total score40%*25%*15%*20%*
General submission requirements

Submit collected data for at least 6 measures, or a complete specialty measure set; and

  • One of these measures should be an outcome measure (or another high priority measure)
  • You’ll need to report performance data for at least 70% of the patients who qualify for each measure (data completeness).

For Performance Year 2021, you’re required to use an Electronic Health Record (EHR) that meets the 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of both for participation in this performance category.

Promoting Interoperability performance category measures are organized under 4 objectives - electronic prescribing, health information exchange, provider to patient exchange and provider to registry exchange (unless an exclusion is claimed). In addition to submitting measures, clinicians must:

  • Submit a “yes” to the Prevention of Information Blocking Attestation,
  • Submit a “yes” to the ONC Direct Review Attestation; and
  • Submit a “yes” for the security risk analysis measure

Participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2021)

  • 2 high-weighted activities, or
  • 1 high-weighted activity and 2 medium-weighted activities, or
  • 4 medium weighted activities
Medicare uses cost measures that assess:
  • The overall cost of care provided to Medicare patients with a focus on the primary care they received,
  • The cost of services provided to Medicare patients related to a hospital stay, and
  • Costs for items and services provided during 18 episodes of care for Medicare patients.
  • There are 20 cost measures available for Performance Year 2021. 
Collection period
12-month performance period (January 1 - December 31, 2021)
For 90 continuous days or more during 2021
For 90 continuous days or more during 2021
Data submission methods
  • Medicare Part B claims
  • Sign in and upload
  • CMS Web Interface
  • Direct submission via Application Programming Interface (API)
  • Sign in and attest
  • Sign in and upload
  • Direct submission via API
  • Sign in and attest
  • Sign in and upload
  • Direct submission via API
There is no data submission requirement for the Cost performance category. Cost measures are evaluated automatically through administrative claims data.
* This percentage can change due to Exception Applications or Alternative Payment Model (APM) Entity participation. For the Cost category,  f there aren’t enough attributed patients for any of the 20 measures to be scored, the cost performance category will receive zero weight when calculating your final score and the 20% will be distributed to another performance category (or categories).

When will facility-based measures scoring apply?
Medicare will continue to identify clinicians, groups, and virtual groups eligible for facility-based scoring. These clinicians, groups, and virtual groups may have the option to use facility-based measurement scores for their quality and cost performance category scores.

Facility-based measurement scoring will be used for your quality and cost performance category scores when:
  • You’re identified as facility-based; and
  • You’re attributed to a facility that has a FY 2022 Hospital Value-Based Purchasing (VBP) Program score (we won’t know this until after the 2021 performance period); and
  • The Hospital VBP Program score results in a higher combined quality and cost score than the MIPS quality measure data we calculate for you.

How can WoundReference help eligible clinicians and groups perform well in MIPS? 

  • Quality category: WoundReference provides clinical algorithms/pathways that naturally highlight quality measures that clinicians can more easily meet in wound clinics. By following the algorithms and protocols, not only clinicians can perform well in the MIPS Quality category, but will also practice evidence-based wound care.
  • Cost category: WoundReference’s content and tools are designed with cost-effectiveness in mind. Tools such as the Formulary Module enable clinics to smoothly set up a local wound dressings formulary and save in inventory/supply costs. Another example is the TeleVisit Tool 2.0, which allows efficient use of time for clinicians and patients. 
  • Improvement Activities category: And last but not least, by using WoundReference’s decision support protocols and tools eligible clinicians and groups can easily meet the number of measures required in the Improvement Activities category. See topic "MIPS in Wound Care and Hyperbaric Medicine - Improvement Activities".

More topics on MIPS will be published soon. To find out more about how WoundReference can help clinicians perform well in MIPS, contact us

About the Authors

Elaine Horibe Song, MD, PhD, MBA
Dr. Song is a Co-Founder and Chief Executive Officer of WoundReference, Inc., a clinical and reimbursement decision support & telemedicine platform for wound care and hyperbaric clinicians. With a medical, science and business background, Dr. Song previously served as medical director for a regenerative medicine-focused biotech company in California, and for a Joint Commission International-accredited hospital network. Dr. Song also served as a management consultant for Kaiser Permanente, practiced as a plastic surgeon in private practice and academia, and conducted bench and clinical research in wound healing, microsurgery and transplant immunology. Dr. Song holds a position as Affiliate Professor, Division of Plastic Surgery, Federal University of Sao Paulo, and is a volunteer, Committee Chair of the Association for the Advancement of Wound Care. She has authored more than 100 scientific publications, book chapters, software registrations and patents.
With over four decades of healthcare experience, Jeff currently holds the position of Principal Partner at Midwest Hyperbaric LLC and the Co-founder and Chief Clinical Officer of Wound Reference. Jeff has excelled in critical care throughout his career, devoting almost a decade as a Flight Respiratory Therapist/Paramedic for the Spirit of Kansas City Life Flight. In 1993, Jeff transitioned into the field of Hyperbaric Medicine and Wound Care, where he committed 21 years of his career to serving as the Program Director for a 24/7 Level 1 UHMS Accredited facility with Distinction. In this role, he continued to provide patient care while overseeing all administrative, clinical, and daily operations within the Wound Care and Hyperbaric Facility. Jeff is a Registered Respiratory Therapist and a Certified Hyperbaric Technologist (CHT). He has also undergone training as a UHMS Safety Director and a UHMS Facility Accreditation Surveyor. Jeff currently serves as a member of the UHMS Accreditation Council, the UHMS Accreditation Forum Expert Panel, and the UHMS Safety Committee. Additionally, he is an esteemed member of the NFPA 99 Hyperbaric and Hypobaric Facilities Technical Standards Committee. Jeff's dedication to the field has earned him numerous prestigious awards. In 2010, he received the Gurnee Award, which honored his outstanding contributions to undersea and hyperbaric medicine. Three years later, in 2013, he was awarded the Paul C. Baker Award for his commitment to Hyperbaric Oxygen Safety Excellence. Most recently, in 2020, Jeff was honored with "The Associates Distinguished Service Award (UHMSADS)," a recognition reserved for exceptional Associate members of the Society who have demonstrated exceptional professionalism and contributions deserving of the highest accolades.
An Advanced Certified Hyperbaric Registered Nurse and Certified Wound Specialist with expertise in billing, coding and reimbursement specific to hyperbaric medicine and wound care services. UHMS Accreditation Surveyor and Safety Director. Principal partner of Midwest Hyperbaric LLC, a hyperbaric and wound consultative service. Tiffany received her primary and advanced hyperbaric training through National Baromedical Services in Columbia South Carolina. In 2021, Tiffany received the UHMS Associate Distinguished Service Award. "This award is presented to individual Associate member of the Society whose professional activities and standing are deemed to be exceptional and deserving of the highest recognition we can bestow upon them . . . who have demonstrated devotion and significant time and effort to the administrative, clinical, mechanical, physiological, safety, technical practice, and/or advancement of the hyperbaric community while achieving the highest level of expertise in their respective field. . . demonstrating the professionalism and ethical standards embodied in this recognition and in the UHMS mission.”
Cathy Milne, APRN, MSN, CWOCN-AP
Advanced Practice Wound, Ostomy Continence Nurse at Connecticut Clinical Nursing Associates Connecticut Clinical Nursing Associates American University
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