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Understanding MIPS Reporting and Performance Metrics

By TherapyNotes, LLC on December 6, 2017
TherapyNotes - Mental Health Providers and the Quality Payment Program

The Merit-based Incentive Payment System (MIPS) is scheduled to roll out gradually starting with specific classes of eligible providers, but virtually all Medicare providers will be required to participate in MIPS by 2019. (To see when you may be eligible for MIPS, check your MIPS participation status.) Many providers have chosen to submit data early to gain a better understanding of how the program works and the impact it could have on their revenue. 

MIPS replaces PQRS, Meaningful Use, and the Value-Based Modifier with new reporting categories: Quality, Advancing Care Information, and Cost, plus Improvement Activities, a brand-new reporting category. Each of these categories include specific measures providers should report, and providers earn points based on the data reported.



The MIPS Quality measures are similar to PQRS measures; they are specific, evidence-based practices that the Centers for Medicare and Medicaid Services (CMS) encourage providers to follow. These Quality measures account for the largest percentage (60%) of your overall MIPS Performance score.

Out of 271 total measures to report, there are 25 measures specific to mental health services. The Quality Measures search tool may help you sort through all of the available measures to determine which may be most appropriate to report for your practice. Look through the list carefully - there may be small changes you can make to your workflow that apply to several measures at the same time. This can minimize the disruption to your practice while still allowing for full participation. For example, several of the Quality measures involve screening for depression, often with the PHQ-9. Making that a regular part of your sessions could potentially fulfill your reporting needs for this category.


Advancing Care Information

Advancing Care Information measures replace Meaningful Use criteria. These measures focus on encouraging providers to utilize technology effectively to promote interoperability and information exchange with both other providers and clients. Advancing Care Information measures account for 25% of your MIPS Performance score.

For this portion of your MIPS Performance score, measures include completing simple tasks with certified EHR technology (CEHRT) such as sending messages through a portal, allowing a client to access care information through a portal, or conducting a risk assessment (which is required by HIPAA anyway!). For most measures, providers must simply report the numerator/denominator or yes/no. The Advancing Care Information search tool provides a list of the Advancing Care Information measures.

For providers that do not use CEHRT, CMS offers hardship exceptions which may be provided if you meet a range of criteria including lack of connectivity or circumstances outside of your control. Learn more about hardship exceptions.


Improvement Activities

Improvement Activities is a new category under MIPS and seeks to improve the quality of care by increasing coordination between providers, engaging with clients and family members, providing telehealth services, and more. Improvement Activities account for 15% of your MIPS Performance score.

To earn the maximum number of points in the Improvement Activities category, you must complete four of the 93 available activities for at least 90 days each. Eight of these activities are specifically for mental and behavioral health providers and focus on the use of screening tools, such as for tobacco use, alcohol use, and depression. The Improvement Activities search tool lists the available activities.



The MIPS Cost category does not require special data submission. Instead, your performance in the Cost category is calculated from adjudicated claims. At this time, cost is not used to determine payment adjustment, but CMS intends to utilize this category beginning in 2018.


Careful planning and small adjustments to your current workflow could help you meet MIPS Performance requirements and possibly earn a positive payment adjustment. We'll continue to provide you with resources to help you prepare for MIPS, including how to collect and submit data. For more details on what you can expect to report, read What To Report on the QPP website, and subscribe to our blog to receive instant email updates when we post new information.

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*The content of this post is intended to serve as general advice and information. It is not to be taken as legal advice and may not account for all rules and regulations in every jurisdiction. For legal advice, please contact an attorney.


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