MIPS reporting services and MACRA QPP support

What is MIPS, and how is it different from MACRA?

The Merit-based Incentive Payment System (MIPS) is one of two tracks in the Quality Payment Program. The other is an Advanced Alternative Payment Model (APM). CMS says the Quality Payment Program was created through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

So MACRA is the law and MIPS is one track under it. In the CY 2026 Physician Fee Schedule final rule, CMS says MIPS clinicians get a positive, neutral or negative payment adjustment based on four performance categories: cost, quality, improvement activities and Promoting Interoperability.

Which year does each number on this page apply to?

Every number here applies to performance year 2026, the 2028 MIPS payment year, unless a line says otherwise. MIPS pays two years behind: 42 CFR 414.1320(e) sets the quality and cost performance period as the calendar year two years before the payment year.

CMS resets measures and benchmarks each year in rulemaking. Check any figure against the year you report on qpp.cms.gov.

Who has to report MIPS, and who is exempt?

You report MIPS if you are a MIPS eligible clinician: an eligible clinician who is not excluded. Under 42 CFR 414.1305 that includes physicians and the other listed practitioner types, such as therapists, audiologists, clinical psychologists, dietitians, clinical social workers and certified nurse midwives, each identified by a unique TIN and NPI pair.

Under 42 CFR 414.1310(b)(1), three groups are excluded for a year:

• A Qualifying APM Participant (QP).
• A Partial QP who does not elect to take part in MIPS.
• A clinician or group that does not exceed the low-volume threshold.

Under 42 CFR 414.1305, for payment year 2023 and later, the low-volume threshold applies to a clinician or group with allowed charges for covered professional services of $90,000 or less, 200 or fewer Medicare Part B patients, or 200 or fewer covered professional services to Part B patients. You must exceed all three to be required to report.

If you exceed at least one but not all three, you may opt in and be treated as a MIPS eligible clinician, per 42 CFR 414.1310(b)(1)(iii)(A). New Medicare-enrolled clinicians are not MIPS eligible until the following year, per 42 CFR 414.1310(c).

CMS makes the low-volume call from a 24-month determination period. For performance year 2026 that is October 1, 2024 through September 30, 2025, then October 1, 2025 through September 30, 2026. If the first segment shows you under the threshold, you stay excluded whatever the second shows (42 CFR 414.1305).

Are hospital-based clinicians exempt from MIPS?

No. Hospital-based is not one of the exclusions in 42 CFR 414.1310(b). A hospital-based clinician is still a MIPS eligible clinician unless a real exclusion applies, and what changes is how some categories are scored.

42 CFR 414.1305 defines a hospital-based clinician as one who furnishes 75 percent or more of covered services in inpatient hospital, on-campus or off-campus outpatient, or emergency room settings, using place of service codes from the MIPS determination period. A group qualifies if more than 75 percent of the NPIs billing under its TIN do. Emergency groups often fall into this test, so check your own claims mix.

Under 42 CFR 414.1380(c)(2), a hospital-based clinician can have the Promoting Interoperability weight redistributed. If the clinician submits Promoting Interoperability data, the 25 percent weight is applied and is not redistributed.

Separately, 42 CFR 414.1380(e) offers facility-based measurement to clinicians with 75 percent or more of services in inpatient hospital, on-campus outpatient or emergency room settings over a 12-month segment starting October 1, two years before the performance period. Quality and cost scores then come from the facility's Hospital Value-Based Purchasing score, with no data submission for an individual. A facility-based group must still submit improvement activities or Promoting Interoperability data.

What are the MIPS performance categories and their weights?

MIPS has four performance categories. Under 42 CFR 414.1330(b)(5), 414.1350, 414.1355(b) and 414.1375, they carry these weights of the 0 to 100 final score for payment year 2028. Submission minimums come from 42 CFR 414.1325(a).

Those are the minimum data elements for a valid submission. A good score depends on the measures chosen and how you perform against benchmarks.

42 CFR 414.1380(c)(2) redistributes weight when a category cannot be scored, such as under a hardship exception or for a non-patient facing, hospital-based or ASC-based clinician.

How do MIPS payment adjustments work?

Your final score is compared with the performance threshold, which is 75 points for payment year 2028. Under 42 CFR 414.1405(b)(9) and (10), 75 points applies to payment years 2024 through 2030, and the CY 2026 final rule set the 2028 through 2030 figure.

At exactly the threshold the adjustment is 0 percent. Above it, the adjustment rises on a linear sliding scale to the applicable percent at a score of 100. Below it, the adjustment falls on a linear scale to the negative of the applicable percent. Under 42 CFR 414.1405(c), the applicable percent is 9 percent for payment year 2022 and every later year.

Positive adjustments can be multiplied by a scaling factor of up to 3.0 so that increases match decreases (budget neutrality), per 42 CFR 414.1405(b)(3). CMS does not know the scaling factor in advance, so no one can promise you a specific positive percentage.

The additional exceptional performance adjustment was specified only for payment years 2019 through 2024 (42 CFR 414.1405(d)). It does not apply to 2028.

How do individual and group reporting differ?

An individual reports under their own TIN and NPI pair, and a group reports under one TIN. 42 CFR 414.1305 defines a group as a single TIN with two or more eligible clinicians, at least one of them a MIPS eligible clinician, who have reassigned billing rights to that TIN.

Under 42 CFR 414.1310(e), when a group reports, each MIPS eligible clinician in it gets a final score based on the group's combined performance. The group must aggregate data across the TIN, and for Promoting Interoperability must include all MIPS eligible clinicians in the TIN for whom it has EHR data.

Two other formats exist. A virtual group is two or more TINs, each a solo practitioner or a group of 10 or fewer clinicians, that elect to combine. A subgroup is a subset of a group, identified by the group TIN, a subgroup identifier and each clinician's NPI.

If CMS gets several submissions from different organizations for the same clinician or group, 42 CFR 414.1325(f) says it scores each and keeps the highest in quality and improvement activities. From one organization, it scores the most recent.

How is MIPS data submitted, and what happens if we miss the deadline?

Under 42 CFR 414.1325(e)(1), data submitted by the direct, login and upload, or login and attest routes is due March 31 following the close of the performance period, or a later date CMS specifies. For performance year 2026, that is March 31, 2027 unless CMS announces otherwise.

Medicare Part B claims work differently. Under 42 CFR 414.1325(e)(2), the data sits on claims with dates of service in the performance period, processed within 60 days after it closes. The routes below are in 42 CFR 414.1325(b) and (c).

The regulation gives no separate penalty for a late submission and no grace period of its own. The consequence runs through the final score: a score from 0 to 18.75 takes the full 9 percent reduction. Whether CMS accepts data after the posted deadline is a question for qpp.cms.gov for that year.

Intermediaries can submit for you. 42 CFR 414.1400 lists a qualified clinical data registry (QCDR), a qualified registry and a CMS-approved survey vendor, and a health IT vendor before the CY 2025 performance period. Claims-based quality data cannot go through one. Which route fits your EHR, specialty and size is settled on a call before reporting starts.

What are MIPS Value Pathways (MVPs)?

A MIPS Value Pathway (MVP) is a subset of measures and activities, set through rulemaking, that CMS groups around a specialty or condition. 42 CFR 414.1365 lets CMS use MVPs to assess quality, cost, improvement activities and Promoting Interoperability. Traditional MIPS still exists, and CMS says in the CY 2026 final rule that it intends to sunset it in a future year.

• Registration runs April 1 to November 30 of the performance year, or a later date CMS specifies (42 CFR 414.1365(b)).
• Quality is four measures, including one outcome measure or, if none exists, one high priority measure, plus one population health measure (414.1365(c)).
• Improvement activities is one activity, or recognized patient-centered medical home participation (414.1365(c)(3)(ii)).
• Promoting Interoperability follows the same requirements as traditional MIPS.

From the CY 2026 performance period, 42 CFR 414.1365(b)(2)(iv) requires a group to attest that it is single-specialty or a multispecialty group that meets the small practice requirements. The final rule says multispecialty groups wanting to report MVPs must currently divide into subgroups.

The CY 2026 final rule finalizes six new MVPs: Diagnostic Radiology, Interventional Radiology, Neuropsychology, Pathology, Podiatry and Vascular Surgery. The full inventory is on qpp.cms.gov.

What are APMs and Advanced APMs, and how do they affect MIPS?

An Alternative Payment Model (APM) is a CMS payment model such as a section 1115A model or the Shared Savings Program. An Advanced APM is one that meets extra criteria, and clinicians who meet the QP thresholds in one are excluded from MIPS.

Under 42 CFR 414.1415, an Advanced APM must require certified EHR technology, base payment partly on quality measures (including an outcome measure unless none applies), and meet financial risk and nominal amount standards or be an expanded Medical Home Model.

42 CFR 414.1430(a) lists the Medicare Option QP payment amount threshold as 50 percent for 2026 and 75 percent for 2027 and later, and the QP patient count threshold as 35 percent for 2026 and 50 percent for 2027 and later. Partial QP thresholds are lower, and Partial QPs are excluded from MIPS only if they do not elect it.

How we handle MIPS and MACRA reporting

Nucleus Align is a US medical billing and revenue cycle management company, and MIPS and MACRA reporting is one of our 22 services. We have billed for US practices since 2018. We work with hospitals, emergency departments and freestanding ERs, urgent care networks, large groups and health systems.

We do not promise scores or payment adjustments. The rules above decide those, and CMS sets the benchmarks each year. What we do is work from the regulation for the performance year, so you know which TINs and NPIs are covered, which categories apply, what is due and when.

Reporting data comes from the same charts and claims your billing runs on. That is why it sits beside professional medical billing, billing and coding audits and CCM and RPM billing, all part of revenue cycle management. For large organisations, see billing for large groups and health systems.

To go through your TINs, NPIs and EHR for the year, book a call.