The Medicare Merit-Based Incentive Payment System (MIPS)
A Guide for Audiologists and Speech-Language Pathologists
Effective January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) included audiologists and speech-language pathologists (SLPs) in the Merit-Based Incentive Payment System (MIPS). ASHA estimates less than 1% of members were required to participate in MIPS in 2022. The MIPS payment adjustment—applied in 2026 based on a clinician's performance in 2024—is +/- 9%.
MIPS participation is separate from the claims-based outcomes reporting requirement for Medicare Part B therapy services, often referred as 'functional limitation reporting' (FLR), which was eliminated for dates of service on or after January 1, 2019.
Navigating MIPS
- Who Must Participate?
- Exemption from MIPS Reporting
- Opting-In or Voluntary Reporting
- Group Practices: Choosing Individual or Group Reporting
- MIPS Participation and Performance Categories
- How do the Payment Adjustments Apply?
- Other Performance Categories
- Resources
Who Must Participate?
Audiologists and SLPs who exceed the low-volume threshold, are not otherwise exempt, and provide services to Medicare Part B patients in the following settings must participate in MIPS reporting.
- Independent private practices
- Group practices
- University clinics not associated with a hospital medical center
- Outpatient clinics not associated with a hospital medical center
- Critical access hospitals (CAHs) that have elected Method II billing (check with hospital administration)
Clinicians working in facility-based settings (e.g., hospitals, skilled nursing facilities, etc.) are not eligible to participate in MIPS. MIPS reporting only occurs in settings where individual NPI numbers and Current Procedural Terminology (CPT) codes are indicated on claims.
Clinicians can use the MIPS Eligibility and Participation Quick Start Guide [PDF] and the Quality Payment Program Lookup Tool to help determine MIPS eligibility.
See also: How MIPS Eligibility is Determined
Low-Volume Threshold
To reach the low-volume threshold, a clinician must meet all three of the following criteria in a calendar year.
The individual clinician must
- see 200 or more Medicare beneficiaries;
- provide 200 or more covered professional services (defined as a single line item on the claim); AND
- receive $90,000 or more in reimbursement from Medicare.
Clinicians can use the Quality Payment Program Lookup Tool to help determine whether you've met the low-volume threshold and are eligible for MIPS participation.
Exemption from MIPS Reporting
A clinician who provides Medicare Part B services in the appropriate settings can still be exempt from mandatory MIPS reporting for any one of the following reasons.
- The clinician is newly-enrolled in Medicare. In this case, they are exempt for that reporting year.
- The clinician is deemed a qualifying or partially qualifying participant of an alternative payment model (APM).
- The clinician does not exceed the low-volume threshold.
A clinician who is exempt from mandatory reporting for any of these reasons may choose to participate in the MIPS program in one of two ways—opting-in or voluntary reporting.
Opting-In or Voluntary Reporting
A clinician who is exempt from MIPS reporting can still participate in the program through voluntary reporting or by opting-in to MIPS.
Voluntary reporting allows you to practice reporting without being subject to MIPS incentive payments or penalties. This may be helpful if you are considering opting-in or if the MIPS program expands its mandatory reporting criteria to include more clinicians in the future.
Opting-in to the MIPS program allows you to earn the MIPS incentive or risk the MIPS penalty. To opt-in, you can only exceed one or two of the three low-volume threshold criteria in addition to other criteria outlined by CMS. Opting-in might be attractive if you were previously successful under the Physician Quality Reporting System (PQRS). Keep in mind that opting-in subjects you to a positive, neutral, or negative payment adjustment based on your MIPS performance.
Contact CMS for information on how to opt-in or voluntarily report at QPP@cms.hhs.gov, 1-866-288-8292, or 1-877-715-6222 (TTY).
Group Practices: Choosing Individual or Group Reporting
Group practices (two or more clinicians) should decide whether clinicians will report as individuals, as part of the group, or both (individually and as part of the group). Keep in mind that mandatory reporting only applies to individual clinicians, not the group.
If each individual clinician in the group is exempt from MIPS reporting, they are not required to report even if they collectively meet the reporting requirements as a group.
If any individual member of the group is a required to participate in MIPS, the practice can elect to report as a group, though it is not required. When a practice elects to participate in group reporting, all clinicians in the group must report. In this case, clinicians could report as both an individual and as a group. CMS will assess both the individual and group score and use the better score to determine the payment adjustment.
See also: MIPS Individual or Group Reporting and 2024 Virtual Group Tool Kit [ZIP]
Group Practice Reporting Scenario
Scenario: Four physicians and two audiologists see Medicare Part B patients in a private practice. Each individual physician is required to report because they meet all MIPS eligibility criteria. However, the audiologists are not required to report because they are individually exempt.
The private practice has several reporting options in this scenario:
- The audiologists elect not to participate in MIPS and the physicians report as individuals, as required. The group is not reporting.
- The audiologists participate voluntarily to gain experience with the program and the physicians report as individuals, as required. The audiologists would not be subject to the penalty or incentive. The group is not reporting.
- The audiologists opt-in to MIPS and the physicians report as individuals, as required. Like the physicians, the audiologists could earn the incentive but also risk the penalty. The group is not reporting.
- The practice determines they will report as a group. This means everyone in the group, including the audiologists, will be required to report.
- The practice decides that all clinicians will participate as both individuals and as a group to improve the chances of earning a neutral or positive MIPS payment adjustment.
MIPS Participation and Performance Categories
MIPS participation and scoring starts over each calendar year. For example, the 2024 performance period begins January 1, 2024, and ends December 31, 2024. Payment adjustments based on 2024 reporting will only apply to Medicare payments in 2026. If you get a different score in the next calendar year (2025), it will only apply to payments made in 2027 and so on. You should begin reporting as close as possible to January 1 of each year to improve your chances of successful participation.
Clinicians participating in the MIPS program receive a composite score based on their performance on each of four performance categories—quality, improvement activities (IAs), promoting interoperability (PI), and cost.
Only three of the four MIPS performance categories apply to audiologists and SLPs in 2024—quality measures, promoting interoperability, and improvement activities. The associated weight of the resource use category will be redistributed to the applicable categories for scoring purposes.
See also: CMS 2022 Measures and Activities for Audiologists and SLPs [PDF]
Reporting Quality Measures
The quality performance category is based on quality measures developed through a qualified clinical data registry (QCDR) or with legacy measures formerly used in the Physician Quality Reporting System (PQRS). The legacy PQRS measures are primarily process-based—as opposed to outcomes-based—and are more general, such as tobacco-use screening and cessation intervention.
How it Works
Quality measures can be reported in a variety of ways, including through Medicare Part B claims, electronic health records (EHRs), or registries. Most audiologists and SLPs will likely report on their Medicare Part B claims, unless they are connected to a larger practice. The CMS claims submission quick start guide [PDF] includes helpful tips for successful participation for the quality performance category.
Each quality measure includes specifications [ZIP] that indicate when a clinician should report on that measure. These specifications include the service provided (based on CPT codes) and specific patient characteristics (for example, age or diagnosis).
To report on a quality measure, you will add specific MIPS-related G-codes to your claim form for all qualifying visits with a patient. A qualifying visit is when an encounter meets all the specifications required for reporting one or more quality measures.
Benchmark for Successful Participation: Clinicians must report on at least six measures and all qualifying visits for those measures. In 2024, audiologists have twelve measures and SLPs have eight available for reporting. Successful reporting means that a MIPS quality data code (QDC) indicating performance met for that quality measure was included on the claim.
2024 Quality Measures
The reporting period for the quality performance category is the 2024 calendar year. Reporting in 2024 will determine payment adjustments in 2026, which could be as much as +/-9% in the 2026 payment year.
Clinicians should report on all qualifying visits for at least six quality measures when six measures are available. There are twelve quality measures for audiology reporting and eight for SLP reporting.
Measures for audiologists:
- Measure 130: Documentation of Current Medications in the Medical Record
- Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Measure 155: Falls: Plan of Care
- Measure 181: Elder Maltreatment Screen and Follow-Up Plan
- Measure 182: Functional Outcome Assessment
- Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation
- Measure 261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
- Measure 318: Falls: Screening for Future Falls Risk
- Measure 431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling
- Measure 487: Screening for Social Drivers of Health
- Measure 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (New for 2024)
- Measure 498: Connection to Community Service Provider: Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs) (New for 2024)
Measures for SLPs:
- Measure 130: Documentation of Current Medications in the Medical Record
- Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Measure 181: Elder Maltreatment Screen and Follow-Up Plan
- Measure 182: Functional Outcome Assessment
- Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation
- Intervention
- Measure 291: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s
- Disease (New for 2024)
- Measure 487: Screening for Social Drivers of Health (New for 2024)Measure 498: Connection to Community Service Provider (New for 2024)
Reporting Improvement Activities
Improvement activities (IAs) are activities that may not involve direct patient care but can improve the quality of care. An example of an IA is when a clinician implements extended office hours on evenings or weekends. This activity could help decrease the number of emergency room admissions. There are more than 100 IAs to choose from [ZIP], giving audiologists and SLPs some flexibility in this category. The CMS IA quick start guide [PDF] includes helpful tips for successful participation in this performance category.
How it Works
To receive credit for IAs, clinicians must attest that they have been completed through the Quality Payment Program (QPP) Portal. The list of IAs and information on attestation can be found on the CMS QPP website. It is important for clinicians to include documentation in their records to outline and support the actions they have taken to complete the IAs.
Unlike the quality category, selection of IAs is largely driven by the unique circumstances of the clinician and not factors like CPT codes or patient characteristics.
Benchmark for Successful Participation: Medicare assigns a medium weight (10 points) or high weight (20 points) to the IAs based on their difficulty and relevance to quality improvement. A clinician must earn 40 points by completing a combination of medium and/or high-weighted IAs to successfully participate in this category. Each IA must be performed during a single, continuous 90-day period (or longer) during the calendar year unless otherwise stated in the activity description.
A clinician can achieve 40 points by reporting:
- 4 medium-weighted activities;
- 2 high-weighted activities; or
- 2 medium-weighted and 1 high-weighted activity.
Reporting Promoting Interoperability
The MIPS Promoting Interoperability (PI) performance category is designed to incentivize the electronic exchange of information using certified electronic health record technology (CEHRT). Policymakers believe that this electronic exchange of health information improves patient access to their health information; improves care coordination between healthcare providers; and allows for the systemic collection, analysis, and interpretation of healthcare data to improve the quality and outcomes of care. The PI Quick Start Guide developed by CMS provides greater detail on reporting for this category. The full measure specifications are also available in the QPP Resource Library [ZIP].
PI Measures
ASHA members will likely qualify for exclusions to reporting on several of these measures and must apply for these exclusions as part of the data submission process.
| Objectives | Measures | Measure Exclusions |
Available Points |
|---|---|---|---|
| e-Prescribing | e-Prescribing | Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period. | 1-10 points |
| e-Prescribing | Query of PDPM |
(1) Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period. (2) Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period. (3) Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023. |
10 points |
| Health Information Exchange |
Option 1 Support Electronic Referral Loops by Sending Health Information |
Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period. | 1-15 points |
| Health Information Exchange |
Option 1 Support Electronic Referral Loops by Receiving and Reconciling Health Information |
Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period. | 1-15 points |
| Health Information Exchange | Option 2 | No exclusion available | 30 points |
| Health Information Exchange | Option 3 | No exclusion available | 30 points |
| Provider to Patient Exchange | Provide Patients Electronic Access to Their Health Information | No exclusion available | 1-25 points |
| Public Health and Clinical Data Exchange |
Report to the following public health or clinical data registries:
|
Generally speaking, the exclusions are based on the following criteria:
|
25 points for the objective |
|
Public Health and Clinical Data Exchange |
Option to report one of the following public health agency or clinical data registry measures:
|
Optional measures (no exclusions available) |
5 bonus points |
How It Works
Clinicians subject to this performance category must report on the PI measures for a minimum of 180 days continuously. In other words, the performance period is not a full calendar year but rather roughly 6 months (e.g. January 1 – June 30). There are 3 ways to submit data:
- Sign in and attest. (You can sign in to your account on the Quality Payment Program website and manually report Promoting Interoperability measures.)
- Sign in and upload. (You or a third party intermediary can sign in to your account on the Quality Payment Program website and upload a file in a CMS-approved format.)
- Direct submission via Application Programming Interface (API). An API is an authorized third party intermediary such as a Qualified Clinical Data Registries (QCDRs) or a Qualified Registries that can perform a direct submission.
How do the Payment Adjustments Apply?
Depending on the outcome of 2023 reporting, a positive or negative payment adjustment of as much as 9% will be applied on all 2026 Medicare claims submitted for services provided by the individual clinician. Clinicians exceeding the benchmark for successful participation in each of the performance categories are eligible for positive payment adjustments and those who do not exceed the benchmark are subject to a negative payment adjustment.
MIPS is tracked by the Taxpayer Identification Number (TIN) of the practice that submitted the claim with the National Provider Identifier (NPI) of the audiologist or SLP listed on the claim as the "rendering provider." This means that you must meet benchmark requirements in every practice that uses your NPI on the claim as the rendering provider.
Other Performance Categories
Although there are four performance categories under the MIPS program, only quality measures and improvement activities (IAs) currently apply to audiologists and SLPs, as outlined above. The other two categories—promoting interoperability (PI) and cost—do not currently apply due to a lack of relevant metrics for audiologists and SLPs.
Cost: This performance category measures a clinician's cost of care and compares it to a predetermined benchmark. This may be difficult to measure for audiologists and SLPs, as they do not control health care spending and care coordination in the same manner as primary care physicians. As such, this performance category will not be applicable to audiologists and SLPs during the 2023 performance period. Its associated weight in the clinician's total composite performance score will be redistributed to the quality and IAs categories.
Resources
- CMS: QPP Resource Center
- ASHA: The Medicare Quality Payment Program: What Audiologists and SLPs Need to Know
Questions? Contact ASHA's health care policy team at reimbursement@asha.org.
