Learn About MIPS

Reporting Requirement

Scoring Logic

Quality Reporting Requirements

For the 2024 Performance Year (PY), Providers can select from 198 quality measures approved by CMS. Data needs to be collected and submitted for each selected quality measure for the entire 2024 calendar year.

To meet the Quality performance category requirements, a MIPS eligible provider, group, or virtual group can report:

  • 6 quality measures (including at least one outcome measure or high priority measure in absence of an applicable outcome measure) for the 12-month performance period; OR
  • A defined specialty measure set (if the measure set has fewer than 6 measures, all measures within that set need to be submitted)

Data Completeness

For 2024, the data completeness requirement is 75%. Providers need to report performance or exclusion/exception data for at least 75% of patients or encounters that are eligible for the measure’s denominator.

What’s New with Quality in 2024?

  • The quality performance category weight remains 30% for individual MIPS eligible providers, groups, and virtual groups participating in traditional MIPS.
  • There are no bonus points for reporting additional outcome and high priority measures, or end-to-end electronic reporting.
  • CMS finalized a total of 198 quality measures for the 2024 performance period.

PI Reporting Requirements

What’s New with Promoting Interoperability (PI) in 2024?

CMS updated the CEHRT definition to align with the Office of the National Coordinator for Health IT (ONC)’s regulations.

  • In a recent proposed rule, ONC proposed to move away from the “edition” construct for certification criteria.
  • Instead, all certification criteria will be maintained and updated at 45 CFR 170.315.
  • CMS is aligning the definition of CEHRT for QPP with the definitions and requirements ONC currently has in place and may adopt in the future.

CMS is discontinuing automatic reweighting for the following clinician types, beginning with this 2024 performance period:

  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered Dietitians
  • Nutrition Professionals

When participating in MIPS at the APM Entity level (reporting the APP, traditional MIPS or an MVP), APM Entities can choose to report Promoting Interoperability data at the APM Entity level.

CMS increased the performance period to a minimum of 180 continuous days within the calendar year.

PDMP is a required measure beginning with the 2024 performance period.

  • CMS modified the second exclusion for the Query of Prescription Drug Monitoring Program (PDMP) measure beginning with the 2024 performance period so that it reads as follows: Any MIPS eligible clinician who does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs during the performance period.

CMS finalized to require a “yes” response for the Safety Assurance Factors for Electronic Health Record (EHR) Resilience (SAFER) Guide measure beginning with the 2024 performance period.

CMS has added a 3rd option for satisfying the HIE objective for the 2024 performance period, in addition to the 2 existing options. Option 3: Participation in the Trusted Exchange Framework and Common Agreement (TEFCA)

IA Reporting Requirements

The Improvement Activities (IA) performance category focuses on one of the MIPS strategic goals, to use a patient-centered approach to program development that leads to better, smarter, and healthier care.

Improvement Activities are classified into Care coordination, Beneficiary engagement, and Patient safety sub-categories which MIPS eligible providers could select from a list of 106 activities.

MIPS eligible providers or groups can attest to the activities performed for a period of minimum 90 continuous days and qualify for a score in IA category.

At least 50% of the providers (in the group or virtual group) must perform the same activity during any continuous 90-day period, or as specified in the activity description, within the same performance period.

What’s New with Improvement Activities (IA) in 2024?

  • Addition of 5 new IAs, it includes an MVP-specific improvement activity titled “Practice-Wide Quality Improvement in MIPS Value Pathways”.
  • Modification of 1 existing improvement activitiesRemoval of 3 existing improvement activities.

Cost Reporting Requirements

For the 2024 PY, the Cost category is included in the final score and is weighted for 25% of the final score. Cost will be calculated directly by CMS and therefore no submission will be required.

  • Reporting period will be for the full PY in 2024.
  • Individual eligible providers or groups will be scored on 29 measures included in the Cost performance category.
  • Addition of 5 new Episode-based measures.
  • Medicare Spending per Beneficiary (MSPB), Total per Capita Cost measure for all attributed beneficiaries (TPCC) and 27 episode-based cost measures.
  • CMS will calculate Cost category score based on administrative claims data.

Reweighting of Performance Categories

CMS has proposed to discontinue automatic reweighting for the following clinician types beginning with 2024 performance period: Nurse practitioners, Physician assistants, Certified registered nurse anesthetists and Clinical nurse specialists

For 2024 MIPS PY, CMS has finalized redistribution of the performance category weights.

Reweighting Scenario Quality Cost Improvement Activities Promoting Interoperability
No Reweighting Needed
• Scores for all four performance categories 30% 30% 15% 25%
Reweight One Performance Category
• No Cost 55% 0% 15% 30%
• No Promoting Interoperability 55% 30% 15% 0%
• No Quality 0% 30% 15% 55%
• No Improvement Activities 45% 30% 0% 25%
Reweight Two Performance Categories
• No Cost and no Promoting Interoperability 85% 0% 15% 0%
• No Cost and no quality 0% 0% 15% 85%
• No Cost and no Improvement Activities 70% 0% 0% 30%
• No Promoting Interoperability and no Quality 0% 50% 50% 0%
• No Promoting Interoperability and no Improvement Activity 70% 30% 0% 0%
• No Quality and no Improvement Activity 0% 30% 0% 70%

CMS would apply automatic reweighting to the following, beginning with the 2023 performance period:

  • Clinical social workers
  • Small practices
  • No reweighting for certified nurse midwives.

MIPS Value Pathways (MVPs)

The new concept in 2023

Merit-Based Incentive Payment (MIPS) Background

The Centers for Medicare and Medicaid Services (CMS) introduced the Quality Payment Program in 2015 with two tracks: MIPS and Advance Payment Model (APM).

In MIPS, performance-based payment adjustments are made for the services provided to Medicare patients based on a Final Score. Performance is measured across 4 areas – Quality, Improvement Activities (IA), Promoting Interoperability (PI) and Cost.

As the MIPS program has matured, the difficulty of avoiding payment penalties has been steadily increasing. Also, clinicians and stakeholders have expressed that MIPS is overly complex.

What are MVPs?

MVP is a conceptual participation framework applying to future proposals beginning with the 2024 performance year. The MVP framework aims to align and connect measures and activities across the Quality, Cost, PI, and IA performance categories of MIPS for different specialties or conditions. MVPs are based on a specialty, medical condition, or episode of care and are established through the CMS rule- making process.

How are MVPs going to make reporting more meaningful?

Traditional MIPS reporting can be confusing. Scoring logic and the reporting requirement of each category are unique. In addition, there are many measures and activities to choose from, many of which are not relevant to a clinician’s specialty.

The introduction of MVPs is a landmark change aimed at reducing the reporting burden while also moving away from certain activities and measures. Reporting on an aligned set of performance measure options relevant to a clinician’s scope of practice is more meaningful to clinicians, allows patients and caregivers to make more informed choices using comparative performance data and places greater emphasis on patient care. MVPs also reduce barriers to APM participation and support the transition to digital quality measures.

For multispecialty groups, the MVP subgroup reporting option provides a way to report performance information meaningful to the various specialties and teams within the group.

Who can report MVPs?

For the 2024 MIPS performance period, MVPs may be reported by individual MIPS eligible clinicians, multi-specialty groups, single-specialty groups, subgroups, or APM Entities.

What are the reporting requirements of an MVP?

Quality Reporting Requirements

4 quality measures, including 1 outcome measure (or, if an outcome measure is not available, 1 high priority measure, included in the MVP, excluding the population health measure).

IA Reporting Requirements

An MVP Participant must report one of the following: two medium-weighted improvement activities; one high-weighted improvement activity; or participation in a certified or recognized patient-centered medical home (PCMH) or comparable specialty practice.

Foundation Layer Reporting Requirements:

PI Reporting Requirements

The entire set of Promoting Interoperability measures, as a part of the foundation layer, are included in all MVPs.

Population Health Measures

As part of the foundation layer, at the time of MVP Registration, the Participant must select one Population Health Measure. The score from the selected measure is added to the Quality Performance Category of the MVP.




4 quality measures, including 1 outcome measure

2 medium-weighted improvement activities OR one high-weighted improvement activity OR PCMH

no submission required

First steps to prepare for MVP reporting

MVPs will be available for submission in performance year 2024. Being informed about the nuances of the evolution of MVPs will enable clinicians to choose the best possible option for their reporting, aiming to earn positive payment adjustments, simplify the reporting and enable better focus on patient care.

  1. CMS has already finalized 16 MVPs in 2024 Final Rule. Identify whether any of them are related to your specialty:
    • Advancing Cancer Care
    • Advancing Care for Heart Desease
    • Optimal Care for Kidney Health
    • Optimal Care for Patients with Episodic Neurological Conditions
    • Supportive Care for Neurodegenerative Conditions
    • Value in Primary CareAdvancing Care for Heart Disease
    • Advancing Rheumatology Patient Care
    • Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
    • Improving Care for Lower Extremity Joint Repair
    • Patient Safety and Support of Positive Experiences with Anesthesia
    • Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes
    • Focusing on Women’s Health
    • Quality Care for the Treatment of Ear, Nose and Throat Disorders
    • Prevention and Treatment of Infectious disorders including Hipatitis C and HIV
    • Quality Care in Mental Health and Substance use disorders
    • Musculoskeletal Care and Rehabilitative Support
  2. If you identify a relevant MVP, check if you are already submitting for the quality measures. If so, how do your previous year’s scores look like? Then look at the listed IAs to see if you are already reporting on them.
  3. Ideas for an additional MVP that supports meaningful measurement of a specialty, condition or public health priority that is meaningful to patient care can be brought to CMS as they have published guidelines for Candidate Development and Submission.
  4. It is expected that CMS will publish more MVPs in the proposed rule 2025. After reviewing if any of the MVPs pertain to your specialty/practice, send your comments to CMS.
  5. Remember that all PI measures are mandatory unless exceptions are claimed. Review and update your health-IT systems as per the requirements.


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