Quality Payment Program 2020: Changes and Requirements (Part I)

Part I: MIPS Updated Requirements for Eligible Providers in 2020

Editor’s note: This article is the first part of a five-part series on the Centers for Medicare and Medicaid (CMS) Quality Payment Program (QPP) in 2020.

  • Part I will provide an update to the current requirements for MIPS, emphasizing key components that changed in 2020.
  • Part II will discuss the current requirements for the MIPS Quality performance categories.
  • Part III will focus on the current requirements for the MIPS Promoting Interoperability performance categories.
  • Part IV will detail the requirements for the cost and improvement activity performance categories of MIPS and MIPS audit considerations.
  • Part V will review the 2020 QPP Alternative Payment Models and MIPS APMs.

By Michael Stearns, MD, CPC, CFPC, CRC


The Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule Final Rule on November 1, 2019. This document included several updates to the Quality Payment Program (QPP), the CMS’ value-based reimbursement system. CMS created the QPP in response to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Congress subsequently made significant modifications to the MACRA legislation via the Bipartisan Budget Act of 2018, which became public law on February 9, 2018.

These modifications will impact more than 1 million clinicians eligible for one or both of the QPP’s two performance tracks, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). CMS estimates that 880,000 clinicians will be MIPS-eligible in 2020 and between 210,000 and 270,000 clinicians will achieve Qualifying APM Participant (QP) status in 2020.

This five-part series will provide a comprehensive overview of the changes, which providers can then use to develop an informed, strategic approach to value-based care initiatives.

Key MIPS Updates—Payments and Performance

MIPS payment adjustments are based on how eligible clinicians score across four performance categories—quality, cost, improvement activities, and promoting interoperability—during the performance year. The payment adjustments are applied to all Part B allowed payments received by the practice or individual clinician in the corresponding payment year, which is two years after the performance year. (For example, payment adjustments based on 2020 MIPS performance scores will be applied in 2022).

Congress empowered CMS to modify aspects of this program. This year’s changes to MIPS are relatively modest, but impact scoring thresholds and payment adjustments.

Payment Adjustments

MIPS performance scores range from 0-100 points. The score is used to determine whether payment adjustments are negative, neutral, or positive based on a “performance threshold.” Scores below the payment threshold receive negative payment adjustments, scores at the performance threshold receive neutral payment adjustments, and scores above the performance threshold receive positive payment adjustments. The MIPS program must remain budget-neutral, so negative payment adjustments are used to cover the cost of payments to providers whose scores exceed the payment threshold.

Adjustments in payment year 2022 will range from the maximum negative payment adjustment of -9 percent to what CMS estimates will be a positive payment adjustment of +6.25 percent. If this figure turns out to be accurate, this would be a substantially higher positive payment adjustment than payments for the same scores in the 2017 and 2018 performance years. The performance threshold for the 2022 payment year increased from 30 points to 45 points and the “additional performance threshold” designed to reward exceptional performance rose from 75 points to 85 points in 2020 (and will remain at that value in 2021). MIPS-eligible groups and clinicians in the bottom quartile below the 45-point performance threshold (i.e., 11.25 points or less) will receive the maximum negative payment adjustment of -9 percent.

Starting in the 2022 performance year, the MIPS performance threshold will be based on the mean or median performance of all clinicians in the program. Based on this model, roughly half of all clinicians in the MIPS will receive negative payment adjustments in the 2024 payment year. Based on current performance the MIPS performance threshold could increase to a high as 75-80 points, making avoiding penalties more challenging for practices. However, this will make more funds available for high-performing providers.

Summary of Key MIPS Changes for 2020

There were several changes finalized for the 2020 performance year. Table 1 provides an overview of the most significant changes. Additional details will be included in subsequent sections of this article and in Parts II and III of this series.

Table 1: Overview of Changes to MIPS for the 2020 Performance Year
General MIPS Changes20192020
MIPS Performance Threshold30 points45 points
MIPS Additional Performance Threshold (for exceptional performance)75 points85 points
Maximum negative payment adjustment-7 percent-9 percent
Physician Compare Website MIPS Performance DataAvailable in late 2019Available
Quality Performance Category20192020
Data Completeness Criteria60 percent70 percent
Points per measure for large groups (16 or more clinicians) if the data completeness requirement is not met

·       Small practices will continue to receive 3 points if data completeness is not met

New quality measure specialty sets (Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietician, and Endocrinology)Not availableAvailable
Emphasis on not manipulating (i.e., “cherry picking”) quality data based on the data completeness criteria)Retroactive to 2019 reportingTo be enforced
Number of new quality measures83
Number of quality measures removed2642
Promoting Interoperability (PI) Performance Category20192020
Verify Opioid Treatment Agreement Bonus MeasureAvailableRemoved
Percentage of hospital-based clinicians in a group that make the group eligible for reweighting of the Promoting Interoperability Category to 0 percent100 percent75 percent
Query of Prescription Drug Monitoring Program (PDMP) for opioids Promoting Interoperability optional bonus measure reporting requirementNumerator and Denominator valuesYes/No Attestation (retroactive to 2019)
Percentage of clinicians in a group that need to be hospital-based for the PI category to be reweighted to 0 percent .100 percent75 percent
Cost Performance Category  
Added 10 new episode-based measures10 total measures20 total measures
Revised the Medicare Spending Per Beneficiary (MSPB) Measure (renamed to “MSPB-Clinician” (MSPB-C)No distinct models for surgical and nonsurgical attribution MSPB episodesDistinct Surgical vs. nonsurgical attribution models
Revised the Total Per Capita Cost (TPCC) Measure – in particular the attribution modelLess refined attribution modelMore refined attribution model
Improvement Activity Performance Category20192020
Number/Percentage of Clinicians in a Group that are needed to attest to an Improvement Activity for the Group to get credit1 clinician50 percent of clinicians in the group
Clinicians may have different 90-day reporting periods for the same measureN/AConfirmed for 2020
Number of new measures2
Number of modified measures7
Removed measures15

The changes in the maximum negative payment adjustment, increases in the MIPS performance thresholds, and additional payment thresholds for exceptional performance may increase the number of providers that receive negative payment adjustments based on 2020 performance. This will generate additional funds for positive payment adjustments while keeping the program cost neutral. However, as shown in Fig. 1, positive adjustments are relatively limited until practices achieve MIPS scores of approximately 90-plus points.

Figure 1: Projected 2022 payment adjustments based on MIPS performance in 2020


What Hasn’t Changed (Yet)


MIPS eligibility requirements did not change in 2020. Eligibility is determined by clinician types and whether minimum patient or payment volume thresholds have been met. If reporting is a group, eligibility is determined at the group level.

Clinician types eligible for MIPS since the beginning of the program include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse anesthetists. Physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dietitians/nutrition professionals were added in 2019. No new clinician types were added for 2020, and CMS maintained its policy that certified clinical social workers are not eligible for the MIPS.

Payment, Volume, and Procedure Thresholds

These thresholds for MIPS eligibility did not change in 2020. Clinicians or groups must meet all three of the criteria listed in Table 2 to be eligible for MIPS.

Table 2: Unchanged Key MIPS Requirements in 2020
General MIPS Requirements Unchanged in 2020 (Requirements that did not Change in 2020)
Clinician type eligible for MIPSNo change in clinician types. The following clinician types are eligible for MIPS in 2020:

·  Physician (including doctor of medicine, osteopathy, dental. surgery, dental

medicine, podiatric medicine, and optometry)

• Osteopathic practitioner

• Chiropractor

• Physician assistant

• Nurse practitioner

• Clinical nurse specialist

• Certified registered nurse anesthetist

• Physical therapist

• Occupational therapist

• Clinical psychologist

• Qualified speech language pathologist

• Qualified audiologist

• Registered dietitian or nutrition professional

Eligibility ThresholdsNo change to low volume/payment/procedure thresholds for eligibility:

·  Bill more than $90,000 in Part B covered professional services, AND

• See more than 200 Part B patients, AND

• Provide more than 200 covered professional services to Part B patients

Opt-In policy: clinicians, groups and APM entities who exceed 1 or 2 of the above thresholds may opt-in to MIPS eligibility and participation.

Practices and clinicians are excluded from the MIPS if they:

·  Recently enrolled in Medicare

·  Are a Qualifying APM Participant (QP)

MIPS eligibility determination periodNo change: Medicare Part B claims for services provided between two 12-month segments: Oct. 1, 2018, and Sept. 30, 2019 (with a 30-day claims run out period), and between Oct. 1, 2019, and. Sept. 30 2020. Clinicians and groups must qualify during both 12-month segments to be eligible for MIPS in 2020.
Quality Performance Category (Requirements that did not Change in 2020)
Category Weighting45 percent
Minimum Points per Measure for Small Groups (15 or fewer clinicians)3 points
Number of points per measure if data completeness is met but case minimum is not met (regardless of practice size)3 points
Quality Measure Bonuses (requires data completeness, case minimum and performance rate > 0)·  2 points/measure for additional outcome measures

·  1 point/measure for additional high priority measures

·  1 point/measure for end-to-end electronic reporting (depending on measure)

Small practice quality category bonus6 points
Measures without benchmarks3 points assigned to measure, regardless of actual performance (data completeness must be met)
Reporting periodFull calendar year
Promoting Interoperability (Requirements that did not Change in 2020)
Objectives and MeasuresNo major change in objectives, measures and scoring system (except for removal of the optional Verify Opioid Treatment Agreement bonus measure)
Category Weighting25 percent
Reporting period90 or more continuous days
EHR certification criteriaPractices must use 2015 Edition Certified EHR Technology
Cost Performance Category (Requirements that did not Change in 2020)
Category Weighting15 percent
2019 MeasuresAll ten 2019 measures carried over into 2020
Reporting periodFull calendar year
Improvement Activity Performance Category (Requirements that did not Change in 2020)
Category Weighting15 percent
Reporting period90 or more continuous days

Performance Category Weightings

Each of the four performance categories has a weighting that may change from year to year. The weighting of each MIPS performance category did not change in 2020 (as compared to 2019) (see Fig. 2A).

Though category weightings have not been determined for 2021, calendar year 2022 will mark the program’s sixth year. At that time, CMS is required by statute to implement MIPS in the form originally intended by Congress. The cost category, currently at 15 percent, will increase to 30 percent, and the quality category’s weighting will be reduced to 30 percent (Fig. 2B).

Figure 2A. MIPS Category Weightings in Performance Year 2020

Fig 2B: MIPS Category Weightings in Performance Year 2022

The increase in the cost performance category’s weighting to 30 percent and changes to how the performance threshold is determined (as discussed above) will create challenges for many practices in the 2022 performance year.

Upcoming installments in this series will drill down on the changes to each performance category, then focus on how providers can best integrate these changes into their value-based care strategies.


Michael Stearns ([email protected]), is the founder and CEO of Apollo HIT, LLC.

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