MIPS: An Overview of Major Changes

Our work grows out of a passion for the public realm, and a desire to create work that is both purposeful and playful.


The Medicare Access & CHIP Reauthorization Act (MACRA) launched the Quality Payment Program (QPP) in 2017. The Center for Medicare and Medicaid Services (CMS) established and has progressively refined the Merit-Based Incentive Payment System (MIPS). CMS made many changes for the MIPS 2020 Performance Year. Bizmatics Healthcare Technologies provides a breakdown of those critical changes.
The result of this overview will be in-depth knowledge on how you can obtain positive payment adjustments in treating Medicare beneficiaries. We also summarize proposed changes for MIPS 2021; provide a useful reference checklist, and important dates to remember.

Performance Thresholds and Payment Adjustments

With MIPS 2020, healthcare providers and administrators will see greater performance thresholds. Therefore, final scores need to be higher to achieve positive payment adjustments for the following year. Final points needed to avoid penalties or negative payment adjustments have increased from 30 to 45. Thresholds for exceptional performance have also increased from 75 to 85 points. Payment adjustments could be as high as +9% or as low as -9%. In 2019, the span of payment adjustment ranged from +7% to -7%.

Performance Categories

CMS combines total points from each performance category to create a MIPS 2020 final score. This score determines whether your professional practice will receive a positive, negative, or neutral payment adjustment. Regulators have increased focus on patient outcome measures and other high-priority measures. In an improved understanding of the unique challenges of small and rural practices, CMS has increased flexibility in evaluating data completeness in those areas that qualify.
The performance category weights will stay the same for MIPS 2020. Consistent knowledge of these category weights helps to prioritize staff and financial resources.

performance categories

The quality of care that you deliver to patients (Category weight – 45%).
An increase in data completeness thresholds to 70%, an increase of 10% over the previous performance year. This change has been made to increase incentives for positive patient outcomes. CMS emphasizes that measures not meeting data completeness criteria receive 0 points. Addressing benchmarking (either flattening or topping out) for some measures to avoid the potential for encouraging inappropriate treatment. Addition of new specialty sets. These include the following healthcare disciplines: audiology, chiropractic medicine, endocrinology, speech-language pathology, clinical social work, nutrition/dietitian, and pulmonology. Increased focus on high-priority outcome measures.

The cost of care based on Medicare claims data (Category weight- 15%).
Addition of 10 new episode-based measures.Revision of the existing Medicare Spending per Beneficiary Clinician as well as the Total Per Capita Cost Measures (TPCC). TPCC measures include a combination of Evaluation and Management Services and primary services.MIPS 2020 rules exclude certain clinicians who mainly deliver non-primary care services. Similarly, final rules exclude those specialty groups that are unlikely to be normally responsible for such treatment.CMS is using a different methodology of determining cost measures for medical and surgical patients. Cost measures between the treatment of individuals and groups will differ.

Improvement Activities

Actions that you take to improve patient care, processes, patient engagement, and access to care (Category weight – 15%).

  • Increasing of the clinician participation threshold to 50% of the clinicians in the practice.
  • Addition of two improvement activities.
  • Modification of 7 improvement activities.
  • Removal of 15 improvement activities.
  • Modification in the definition of a rural area
  • Previous to MIPS 2020, there was no formal policy to specifically identify acceptable improvement activities. CMS evaluators may now exclude activities which may be obsolete or are duplicative with another activity.
  • The guidelines for groups (virtual or in-person) activities have new requirements. At least 50% of clinicians must be responsible for performing the specific activity. Specified clinical tasks must occur during a 90-day period within the same performance year.

Promoting Interoperability

The act of sharing important information with other clinicians or with the patient. (Category weight – 25%)

  • The Query of Prescription Drug Monitoring Program (PDMP) is now an optional measure. Clinicians who use the PDMP to promote interoperability are eligible for bonus points.
  • Removal of the Verify Opioid Treatment Agreement Measure.
  • Reduction of the threshold for groups to be considered hospital-based – from 100% to 75%.

MIPS 2020 Performance Category Checklist

Mips Performance


  • Are all treatment periods within establish benchmarks?
  • Are all eligible specialty disciplines on board with new procedures?
  • Are patient outcome measures documented?


  • Is administrative staff as well as providers clear on MIP 2020 episode categories?
  • Are the right non-primary care clinicians delivering care according to MIPS requirements?

Improvement Activities

  • Are clinician participation thresholds at 50% or above?
  • Do improvement activities qualify under MIPS 2020 regulations?

Promoting Interoperability

  • Are any clinicians accessing the PDMP Query…and documenting it?
Looking Ahead to MIPS 2021

Looking Ahead to MIPS 2021

The COVID-19 pandemic has changed our world dramatically, including in matters of quality and cost-effective patient care. CMS recognizes that the highest priority at this time is ensuring that all patients get the healthcare they need. In response to this emergent issue and due to stakeholder recommendations, CMS has delayed several significant changes to MIPS 2021.

CMS had planned a framework for MIPS Value Pathways (MVP). However, it will not be available for reporting until at least the 2022 performance period. Instead, CMS has proposed changes to the MVP guiding principles. Among the changes is increased attention to the patient and support for digital quality measures. Another proposal regarding MVP development is to incorporate measures and activities into all four performance criteria. An Alternative Payment Model (APM) is also incorporated into the MIPS 2021 Proposed Rule as a companion to MVP.

Important Dates to Remember
CMS has numerous deadlines and important dates coming up in MIPS 2020/2021. Keep these dates in mind to stay in compliance and maximize revenue opportunities while providing high-quality patient care to Medicare beneficiaries
December 2020
PY 2020 is finalized
December 31, 2020
PY 2020 Eligibility Ends
Quality Payment Program Exception Applications window closes
Fourth Snapshot for Full TIN APMs (Medicare Shared Savings Program)
January 4, 2021
The submission window opens for PY 2020

March 31, 2021
The submission window closes for PY 2020
Fourth Snapshot for Full TIN APMs (Medicare Shared Savings Program)
July 2021
Performance feedback available (based on data submitted for PY 2020)
The targeted review opens after payment adjustment information is available
August/September 2021
The targeted review closes 60 days after the release of payment adjustment information
January 1, 2022
Payment adjustments based on PY 2020 go into effect

To Wrap Up…

Annual changes to the Merit-Based Incentive Payment Program (MIPS) will undoubtedly continue. The original intent of CMS was indeed to establish a system of continuous improvement that changes with medical evidence and standards of patient care. Bizmatics Health Technologies has created PrognoCIS, a cloud-based, MACRA-certified EHR product that ensures maximum success in documenting the latest MIPS performance categories and regulations.

Related Articles: 

Ready to take it to the next step?

Please fill in your details with the best contact email and phone number.
We look forward to connecting with you.

Thank you. The whitepaper has been sent to your email. You can also click the button below to download it.


Medical practitioner with digital Tablet

Contact Us

All our promotional offers are as individual and unique as the practices and clinics we support.

We look forward to exploring the potential benefits and offers prognoCIS has for you.

Please fill in your details with the best contact email and phone number.

All our promotional offers are as individual and unique as the practices and clinics we support.

We look forward to exploring the potential benefits and offers prognoCIS has for you.

Please fill in your details with the best contact email and phone number.

Need Help?
We're Here To Assist You

Would you like to see an example of this?

Feel free to contact us, and I will be more than happy to answer all of your questions.

Receive the latest news

Subscribe To Our Newsletter

PrognoCIS Demo

We would like to invite you to take a demonstration of PrognoCIS EHR to fully appreciate the depth of content, features and simplicity of use.

Please choose your preferred method of contact.