Each year, the Centers for Medicare and Medicaid Services (CMS) updates the criteria of the Merit-Based Incentive Payment System (MIPS). Here’s what your specialty medical practice needs to know to increase your reimbursement and avoid thousands of dollars in penalties in 2025.
Table of Contents
- What Is MIPS Reporting?
- The 4 Categories Of MIPS Criteria
- How Does MIPS Work?
- 2025 MIPS Criteria Changes
- What Healthcare Providers Participate in MIPS?
- Are There Exceptions to MIPS?
- MIPS FAQs
What Is MIPS Reporting?
MIPS is a program launched in 2017 to tie Medicare reimbursement levels to quality scores rather than patient volume.
Providers are scored on their quality of care, their efforts to improve their practice, whether their systems can exchange data with other health care providers, and cost efficiency.
Each of the MIPS criteria is scored on a 100-point scale, and the composite score determines the provider’s Medicare payment adjustment. Those who score above 75 can increase their payment adjustment, while those who score below 75 can be assessed a penalty. Providers who come in at the neutral score of 75 see no change in their reimbursement.
The 4 Categories of MIPS Criteria
Your MIPS score is a composite of your weighted scores in four categories: quality, improvement activities, promoting interoperability, and cost.
MIPS Quality Category
Quality accounts for 30% of your total MIPS score. To qualify, your practice is required to report on no fewer than six quality measures, including at least one outcome-based or high-priority metric.
There are more than 200 CMS-approved quality measures to choose from, including such activities as screening for tuberculosis before prescribing biologic therapy, connecting vulnerable patients with community resources, and collaborating with a diabetic patient’s primary care physician.
Outcome-based measures include such metrics as the percentage of patients who reported improvement in specific symptoms, while high-priority measures include metrics like biopsy reporting time.
MIPS Improvement Activities Category
This category is meant to encourage innovation and reward healthcare providers for continuous improvement. Improvement activities account for 15% of your total MIPS score.
To participate, you need to complete between two and four approved activities in the reporting period. The minimum depends on factors including practice size and whether you are in an urban or rural area. You have to sustain each activity for at least 90 days, and it also needs to be completed by 50% of the providers in the practice.
There are more than 100 CMS-approved improvement activities to choose from, including things such as medication management, research participation, and individual care plan development.
MIPS Promoting Interoperability Category
The MIPS promoting interoperability category was originally called the Medicare EHR Incentive, or the Meaningful Use Program. It’s intended to encourage healthcare providers to use technology that enables collaboration across care teams.
In essence, it measures your ability to electronically exchange patient health data with providers outside your practice.
Promoting interoperability accounts for 25% of your total MIPS score. To qualify, you must use a certified electronic health records (EHR) system. Since this category makes up a quarter of your composite score, providers who don’t use a certified EHR are automatically assessed a penalty.
For those using a certified EHR, your promoting interoperability score is calculated according to your performance in four objectives: e-prescribing, health information exchange, provider-to-patient exchange, and public health and clinical data exchange.
MIPS Cost Category
Cost makes up 30% of your total MIPS score, and it’s the only category that doesn’t require any reporting from you.
This category evaluates your cost efficiency based on Medicare spending, total per-capita costs, and several episode-based measures.
The Quality Payment Program calculates this score for you using Medicare administrative claims data.
How Does MIPS Work?
The reporting period follows the calendar year, from January 1 through December 31. Each year, MIPS-eligible providers have until March 31 to report data on their quality, improvement, and promoting interoperability activities from the year before.
CMS reviews the data, calculates the provider’s cost measure, and applies a weighted formula to determine the Medicare payment adjustment. The maximum adjustment can be up to 9% in the negative, and positive adjustment is directly related to how many penalties were assessed.
In today’s consumer-led market, these quality-focused scores can also impact your ability to attract new patients. Your MIPS score moves with you, even if you change practices. Every MIPS score you earn is added to the public record published by CMS on its Physician Compare website.
Consumers have more choices today than ever before, particularly when it comes to choosing specialty providers like dermatologists or ophthalmologists. These patients may not care about your Medicare reimbursements, but coming across a high score in quality and communication measures while researching providers is a reassuring sign.2025 MIPS Criteria Changes
Each year, CMS updates the criteria and options in each of the four MIPS criteria categories.
2025 MIPS Quality Changes
You’ll want to review the quality measures you report on for next year’s MIPS, because there’s a good chance they’ve changed.
CMS eliminated 10 formerly approved metrics and replaced them with 7 new measures. Three measures were removed from traditional MIPS but can still be used for MIPS Value Pathways, a newer reporting option that will soon become mandatory.
In addition, CMS made substantive changes to 66 approved quality measures. If these make up any of the six measures you report on, make sure you’re still reporting the right data.
The criteria used to assess the impact of ICD-10 coding updates were revised, and the data completeness threshold stayed at 75%, where it will remain through the 2028 reporting period. To get maximum points for quality, you must report on at least 75% of total patients (Medicare and non-Medicare) who meet the denominator criteria.
2025 Changes to MIPS Quality Criteria |
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10 Measures eliminated |
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7 Measures added |
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66 Measures substantively modified |
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Criteria assessing the impact of ICD-10 coding updates revised |
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Data completeness threshold stayed at 75% |
2025 MIPS Improvement Activities Changes
The Improvement activities category saw some unique changes in the removal of the weighting of the activities and reduced the number of activities to 1 for small practices and 2 for large practices.
Eight previously approved improvement activities were eliminated, and two new activities were added.
2025 Changes to MIPS Improvement Activities Criteria |
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8 Activities eliminated |
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2 Activities added |
2025 MIPS Promoting Interoperability Changes
As technology continues to advance, CMS updated its definition of certified EHR technology.
The minimum performance period maintains at 180 continuous days, and exclusion language in the Query of Prescription Drug Monitoring Program was modified. In addition, the Safety Assurance Factors for Electronic Health Record Resilience Guide question now requires a response of “yes.”
2025 Changes to Promoting Interoperability Criteria |
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Updated definition of certified electronic health record technology (CEHRT) |
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Minimum performance period maintains at 180 continuous days |
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Exclusion language in the Query of Prescription Drug Monitoring Program modified |
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Safety Assurance Factors for Electronic Health Record Resilience Guide required answer modified |
2025 MIPS Cost Changes
QPP calculates cost performance based on 29 cost measures. All providers are measured on two population-based metrics (total per-capita cost and Medicare spending per beneficiary); episode-based metrics are applied as relevant.
New episode-based measures for 2025 include chronic kidney disease, end-stage renal disease, kidney transplant management, prostate cancer, rheumatoid arthritis, and respiratory infection hospitalization.
2025 Changes to Cost Criteria |
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6 episode-based measures added |
Changes were made to the Cataract Episode-based measure, impacting DX codes that are not included along with additional services and medications.
Make reporting easy with an EHR that automates data collection.
What Healthcare Providers Participate in MIPS?
Any clinician who bills for Medicare Part B stands to benefit from participating in either MIPS or in an Alternative Payment Model (APM). Both of these programs are defined by the Medicare Access CHIP Reauthorization Act (MACRA).
If you bill Medicare and you don’t participate in one of these programs, you will be reimbursed at a lower rate on Part B claims. Failure to report quality data is also reported on publicly available websites where consumers can compare healthcare providers.
You can choose to participate in MIPS as an individual or as part of a group. An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). A group – for example, multiple providers reporting as a single practice – is defined as two or more NPIs sharing a TIN.
Whether you choose to participate as an individual or as a group, your choice applies across all four categories. You can’t, for example, opt to report improvement activities as an individual but interoperability as a group.
Are There Exceptions to MIPS?
Not every clinician is required to participate in MIPS. Here are some exceptions:
- Providers who billed less than $90,000 in the reporting year
- Providers who cared for fewer than 200 Medicare patients in the reporting year
- Providers who provide fewer than 200 covered services
- Providers participating in an APM
- Providers who qualify for special status
- Providers affected by an extreme and uncontrollable circumstance, such as a natural disaster
- Providers who claim a hardship that impacts their ability to use an EHR, such as rural clinicians with poor internet connectivity
- Providers who provide 75% or more of their services in hospitals and emergency rooms are exempt from reporting on the promoting interoperability category — they must still report on quality and improvement activities
Look up your practice to see if you are required to participate.
MIPS FAQs
- What happens if you don’t report MIPS data?
If you bill Medicare Part B, you will be docked up to 9% on your payment adjustment. Your failure to report this quality data will also be recorded on physician comparison websites used by consumers when researching providers. - What’s a good MIPS score?
A neutral score is 75 on a 100-point scale. Clinicians who score 75 see no change to their reimbursement. Any score above 75 can result in a positive payment adjustment up to 9% (depending on other factors assessed by CMS). Scoring below 75 can result in a penalty of up to 9%. - Does MIPS improve patient outcomes?
It’s not clear. While that was its intention, recent studies have shown an inconsistent relationship between provider MIPS scores and patient outcomes. - What are the benefits of MIPS?
MIPS rewards providers for proactively taking on initiatives to provide better care. Ideally, these initiatives translate to better outcomes for patients. - What are the challenges of MIPS?
It can be difficult to apply MIPS data to actually improving your practice because of the long delay between serving Medicare patients and receiving data from CMS. - What are MIPS Value Pathways (MVPs)?
Introduced in 2023, MIPS Value Pathways are an alternative to traditional MIPS reporting. Clinicians using MVPs report on fewer quality measures and improvement activities, streamlining the reporting process. - What are APM Performance Pathways?
APM Performance Pathways are an alternative to MIPS Value Pathways. They allow clinicians participating in an alternative payment model (APM) rather than MIPS to use a similar streamlined process.
Not Participating in MIPS Is Leaving Money on the Table
MIPS was established in 2017, but even after all this time, there are still clinicians who don’t participate.
Before, those clinicians were missing out on increased Medicare reimbursements, to the tune of tens of thousands of dollars. Now, the stakes are higher. Not only will nonreporting providers not get extra Medicare money, they stand to lose thousands of dollars to penalties.
We’ve helped specialty medical providers like dermatologists and ophthalmologists collect more than $61 million in MIPS incentives. Better yet, a Nextech EHR can automate most of the reporting for you, taking the hassle out of the process.
Maximize your reimbursements and schedule a consultation today to learn all the ways Nextech can help your practice thrive.
About the Author
Heather Miller has more than 25 years of leadership experience in healthcare operational management, providing comprehensive medical consultation to hundreds of practices. Her expertise includes oversight of revenue cycle management, Medicaid and Medicare compliance, and workflow analysis to increase practice productivity. She has a proven track record in supporting clients in the adoption of electronic health records and providing strategy plans for annual MIPS reporting.
Heather holds a master’s degree in business administration from Rollins College - Crummer School of Business and a second master’s degree in Early Childhood Special from the University of Miami. She completed her undergraduate degree at the University of Tennessee in Special Education.