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Collection period for Medicare's Merit-based Incentive Payment System (MIPS) 2023 started on January 1st, 2023 and ended on December 31, 2023. 

The original March 31 2024 deadline for eligible clinicians to submit MIPS 2023 data for the Centers for Medicare and Medicaid Quality Payment Program (CMS QPP) was extended to April 15, 2024. 

2023 data directly impacts the physician fee schedule payments for the year of 2025.

Likewise, the collection period for MIPS 2024 started on January 1st and will end on December 31, 2024. 2024 data directly impacts the physician fee schedule payments for the year of 2026. MIPS final score will determine whether eligible clinicians receive a negative, neutral, or positive MIPS payment adjustment. Of note, MIPS adjustment does not affect facility payments for services rendered in ambulatory surgical centers or hospital outpatient departments.

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 report data across 3 categories (Quality, Promoting Interoperability, Improvement Activities). For the fourth category - Cost - Medicare collects and calculates data for the cost performance for each eligible clinician, if applicable. 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 2024.

However, if you have not started collecting data for 2024 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 2024 data that you submit (or do not submit) by March 2025. Your Medicare Part B-covered professional services beginning on January 1, 2026. will be affected.

Your MIPS final score will determine whether you receive a negative, neutral, or positive MIPS payment adjustment. The 2024 MIPS payment adjustments vary between -9% and +9%. 

  • Positive payment adjustment for clinicians with a 2024 final score above 75.
  • Neutral payment adjustment for clinicians with a 2024 final score equal to 75.
  • Negative payment adjustment for clinicians with a 2024 final score below 75.

See CMS 2024 Quality Benchmarks User Guide with Scoring Examples.

In the 2024 MIPS, to avoid a payment penalty, eligible clinicians have to score a total of at least 75 overall MIPS points

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 2024 - 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
  • Clinical social workers
  • Certified nurse midwives

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.
  • For more information about eligibility: Review the 2024 MIPS Eligibility & Participation Quick Start Guide.

How can I report for MIPS 2024? 

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 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. The available quality measures might not offer relevant overlap with wound care practices.
  • 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 CMS' 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.  
    • For the 2024 performance year, 16 MVPs are available. For wound care programs, the set "Value in Primary Care" offers some measures that might overlap with their practice, however the available quality measures might not be relevant enough to meet the requirement to report 4 quality measures from the list provided in this MVP set. Examples of quality measures available in this set are:  
      • Quality ID #47 (CBE 0326): Advance Care Plan
      • Quality ID #487: Screening for Social Drivers of Health
      • Quality ID #483 (CBE 3568): Person-Centered Primary Care Measure Patient Reported Outcome

How can I participate in MIPS 2024? 

"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, 4. as an alternative payment model (APM) Entity or 5. Subgroup.

  • 1. Individual: 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 2024, 
    • 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 2024 are: October 1, 2022 to September 30, 2023 and October 1, 2023 to September 30, 2024. Medicare will release final (reconciled) data from the 2 segments in December 2024.  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
  • 2. Group: Collect and submit data for all clinicians in the group.
  • 3. Virtual Group: Collect and submit data for all clinicians in a CMS approved virtual group (traditional MIPS only). Virtual group elections are submitted to CMS prior to the performance year – the virtual group election period for the 2024 performance year closed on December 31, 2023.
  • 4. APM Entity: Collect and submit data for MIPS eligible clinicians identified as participating in the MIPS APM.
  • 5. Subgroup: This is a new participation option only available to clinicians reporting an MVP. Advance registration is required.

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, APM or MVP (Now)
  4. Review the current performance year’s quality measures (Select Performance Year 2024) (Now).  Collect and perform your measure and activities (throughout 2024). For Quality, clinicians must collect data for each measure from January 1 to December 31, 2024. Collection period ranges from 90 to 180 days for other 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. APM: Quality, Promoting Interoperability, Improvement Activities (MIPS APM participants currently receive full credit in the improvement activities performance category)
    3. MVP: Quality, Promoting Interoperability, Improvement Activities, Cost
  5. Verify your eligibility (December 2024)
  6. Submit your data yourself or with the help of a third party intermediary, such as a Qualified Clinical Data Registry (QCDR) or Qualified Registry (January through March 2025)
    1. QCDRs are intermediaries that are authorized by CMS to submit quality measures (MIPS quality measures and/or QCDR measures), Promoting Interoperability measures, and improvement activities on behalf of the MIPS eligible clinician, group, virtual group, subgroup, or Alternative Payment Model (APM) Entity. To identify a QCDR that supports your selected MVP, download the 2024 Qualified Clinical Data Registries (QCDRs) Qualified Posting.
  7. Review your feedback (mid 2025)
  8. Preview your data for public reporting (late 2025 or early 2026)
  9. Note the application of payment adjustments (throughout 2026)

Table 2. Summary of traditional MIPS 2024 - categories, submission requirements and collection period  

NOTE: to visualize columns on the right, scroll down to the bottom of the table and slide it to the right

QualityPromoting InteroperabilityImprovement ActivitiesCost
Percentage of total score30%*25%*15%*30%*
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 75% of the patients who qualify for each measure (data completeness).

For Performance Year 2024, you’re required to use an Electronic Health Record (EHR) that meets the certification criteria at 45 CFR 170.315.

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

  • Provide your EHR’s CMS identification code from the Certified Health IT Product List (CHPL) and submit a “yes” to:
    • The Actions to Limit or Restrict Compatibility or Interoperability of CEHRT (previously named the Prevention of Information Blocking) Attestation.
    • The ONC Direct Review Attestation.
    • The Security Risk Analysis Measure.
    • The Safety Assurance Factors for EHR Resilience (SAFER) Guides Measure (Updated for 2024: a "no" will no longer satisfy this measure in 2024).

Participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2024)

  • 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 29 cost measures available for Performance Year 2024. 
  • There is a “non-pressure ulcer” cost measure under development by CMS, which will be directly relevant to wound care eligible clinicians 
Collection period
12-month performance period (January 1 - December 31, 2024)
For 180 continuous days or more during 2024
For 90 continuous days or more during 2024
Data submission methods
  • You (Individual, Group, Virtual Group, Subgroup, or APM Entity Representative)
    • Medicare Part B claims (small practices only)
    • Sign in to the QPP website and upload (eCQMs and MIPS CQMs)
  • Third-party intermediaries (QCDRs, Qualified Registries, and Health IT Vendors)
    • Sign in to the QPP website and upload (eCQMs, MIPS CQMs and QCDR Measures)
    • Direct submission via Application Programming Interface (API)
  • CMS-Approved Survey Vendors: CAHPS for MIPS Survey Measure
  • 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 Promoting Interoperability category, the following are exempt from reporting Promoting Interoperability data for the 2024 performance year: Clinician type: clinical social workers Special status: ambulatory surgical center (ASC)-based, hospital-based, non-patient facing, and small practice (Note: small practice is the only special status available to APM Entities.). 

There is a “non-pressure ulcer” cost measure under development by CMS, which will be directly relevant to wound care eligible clinicians.

When will facility-based measures scoring apply?

Facility-based scoring may be applied to facility-based clinicians, groups, and virtual groups. Facility-based scoring will be used for your quality and cost performance category scores when all the following conditions are met:

  • You’re identified as facility-based;
  • You’re attributed to a facility with a FY 2024 Hospital Value-Based Purchasing (VBP) Program score (we won’t know this until the end of the 2023 performance period); and
  • The facility-based scoring methodology using your Hospital VBP Program score results in a higher final score than your final score calculated without the application of facility-based measurement

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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