2025 MIPS and MACRA updates: A guide for clinicians and medical billers
Discover critical 2025 MIPS and MACRA updates affecting your practice’s reimbursement, performance thresholds, and scoring changes you need to know now.

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At a Glance
- 2025 MIPS scores (0-100) determine Medicare payment adjustments from -9% to +9% in 2027.
- Small practices get exemptions and scoring advantages, including no interoperability reporting.
- 3 reporting options exist: traditional MIPS, APM Pathway, and specialty-focused MVPs.
Over the last decade, the way in which Medicare pays clinicians has changed significantly. Long gone are the days in which clinicians can automatically earn more money by simply providing more services. While today’s clinicians do continue to receive fee-for-service (FFS) payments, they’re also increasingly held accountable for the quality of the care they render.
It all goes back to a law introduced in 2015 called the Medicare Access and CHIP Reauthorization Act (MACRA). This law reformed the entire Medicare payment system by repealing the Sustainable Growth Rate formula for payment and replacing it with a value-based payment system.
Read on for essential 2025 MACRA and Merit-based Incentive Payment System (MIPS) updates impacting medical practices and billing companies.
What is MACRA?
MACRA is the law that required Medicare to establish valued-based payment models collectively referred to as the Quality Payment Program. Since Medicare implemented this program in 2017, the agency has continued to take steps toward a merit-based incentive payment system that represents a ‘new’ way of thinking about healthcare reimbursement.
What is the Quality Payment Program?
Under this program, payment models reward clinicians who provide high-value, high-quality care with payment increases while simultaneously reducing payments to clinicians who don’t meet performance standards.
What does MACRA mean for patients and clinicians?
Patients are the beneficiaries of MACRA because they receive higher-quality care through the advanced use of healthcare information and more streamlined care coordination. MACRA also promotes patient education, engagement, and empowerment — all good things that can improve outcomes and help patients lead happier, healthier lives.
“Payment models reward clinicians who provide high-value, high-quality care with payment increases while simultaneously reducing payments to clinicians who don’t meet performance standards.”
However, clinicians benefit from MACRA as well because its payment models support them in improving patient satisfaction and providing meaningful care that aligns with value-based principles. Clinicians are paid to do exactly what they were trained (and deeply want) to do: keep patients healthy.
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How does MIPS relate to MACRA?
MIPS is one way in which eligible clinicians can comply with MACRA. (Note: The other way is through advanced alternative payment models [APM] that are not covered in this article.)
According to Medicare, MIPS was designed to “tie payments to quality and cost-efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.”
In performance year 2025, there are 3 MIPS reporting options available to eligible clinicians:
How can you determine MIPS eligibility?
MIPS-eligible clinicians include the following:
- Certified nurse midwife
- Certified registered nurse anesthetist
- Chiropractor
- Clinical nurse specialist
- Clinical psychologist
- Clinical social worker
- Nurse practitioner
- Occupational therapist
- Osteopathic practitioner
- Physical therapist
- Clinician (including doctor of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
- Clinician assistant
- Qualified audiologist
- Qualified speech-language pathologist
- Registered dietitian or nutrition professional
Do clinicians have to participate in MIPS?
The short answer is ‘yes.’ All eligible clinicians in the United States must participate in MIPS. However, there are some exceptions. These include clinicians who qualify for one or more of the following:
- The clinician is a qualifying participant in an advanced APM
- The clinician does not exceed the MIPS low volume threshold
- The clinician is in their first year of participating in the Medicare program
How MIPS low volume threshold is determined
Clinicians are exempt from MIPS if they meet the low volume threshold — meaning they:
- See fewer than 200 Medicare Part B patients. (Attending to the same patient on separate occasions counts as separate services.)
- Bill less than $90,000 in Part B covered professional services per year.
The MIPS Determination Period involves CMS reviewing past and current Medicare Part B claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice each performance year. These reviews determine MIPS eligibility and low-volume criteria. Each time, a review analyzes a 12-month period.
Clinicians and practices generally must exceed the low-volume threshold during each segment of the MIPS Determination Period to be eligible for MIPS.
“Clinicians and practices generally must exceed the low-volume threshold during each segment of the MIPS Determination Period to be eligible for MIPS.”
It’s important to note that clinicians within the low-volume margin can still opt to join MIPS.
Determinations are assessed both individually and within group practice contexts. A clinician might not meet the low-volume threshold when reporting solo and thus be exempt from MIPS. However, if they report as part of a group practice that surpasses the threshold, they are then required to participate in MIPS.
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Determining MIPS eligibility
Clinicians can use this tool to determine MIPS eligibility. If eligible, clinicians may be able to participate at one or more of the following levels: individual, group, virtual group, subgroup, or advanced APM entity.
Clinicians may also have additional choices for participation depending on their chosen MIPS reporting option (i.e., traditional MIPS, APM Performance Pathway, or MVP).
What are the 4 components of MIPS?
The 4 performance categories that potentially drive the final MIPS score are:
- Clinical quality. Measures in this performance category capture the quality of care delivered, and eligible clinicians can choose the ones that best fit their medical practice.
- Promoting interoperability. Measures in this performance category denote patient engagement and the exchange of health information using certified electronic health record (EHR) technology.
- Practice improvement activities. Measures in this performance category reflect how well a clinician improves care processes, enhances patient engagement, and increases access to care.
- Cost. Medicare automatically calculates costs based on administrative claims data.
However, the specific contribution of these components (or lack thereof) to the final MIPS score depends on the reporting option an eligible clinician chooses (i.e., traditional MIPS, APM Performance Pathway, or MVP).

What is a MIPS score, and how is it calculated?
Under MIPS, eligible clinicians report certain data to Medicare and then earn a ‘MIPS performance score’ from 0-100. This score, known as the ‘final MIPS score,’ ultimately determines an eligible clinician’s future Medicare Part B payment adjustment — and particularly whether that adjustment is negative, neutral, or positive.
More specifically, a performance year 2025 final MIPS score affects payment as follows:
- 0.0-18.75: Negative MIPS payment adjustment of -9%.
- 18.76-74.99: Negative MIPS payment adjustment between -9% and 0% based on a linear sliding scale.
- 75.0: 0% adjustment.
- 75.01-100: Positive MIPS payment adjustment greater than 0% on a linear sliding scale. The linear sliding scale ranges from 0 to 9% for scores from 75.00 to 100.00 This sliding scale is multiplied by a scaling factor greater than zero but not exceeding 3.0 to preserve budget neutrality.
However, it’s important to note that there is no immediate impact of MIPS data on payment. In fact, there’s actually a two-year delay. This means the data that eligible clinicians submit during performance year 2025 doesn’t affect payments until 2027. Likewise, current-day payments are based on a clinician’s MIPS score from performance year 2023.
The MIPS performance year begins on January 1. The end date depends on the specific MIPS category.
“The data that eligible clinicians submit during performance year 2025 doesn’t affect payments until 2027.”
For quality and cost, the performance year ends on December 31 each year. To promote interoperability, it ends after 180 consecutive days. And for improvement activities, the end date depends on the specific activities selected.
How are clinicians paid specifically under traditional MIPS?
Under traditional MIPS, a performance year 2025 final MIPS score is based on the following performance categories:
- Clinical quality (30% of the performance year 2025 final traditional MIPS score). In 2025, there are 7 new quality measures, substantive changes to 66 measures, and 10 removed measures.
- Promoting interoperability (25% of the performance year 2025 final traditional MIPS score).
- Practice improvement activities (15% of the performance year 2025 final traditional MIPS score). In 2025, there are 2 new activities, 1 modified activity, and 4 removed activities.
- Cost (30% of the performance year 2025 final traditional MIPS score). In 2025, there are 6 new episode-based cost measures and substantive updates to 2 existing episode-based cost measures.
See the Appendices of the 2025 Quality Program Fact Sheet for more information about new, revised, and deleted measures in each of the categories listed above.
How are clinicians paid under the APM Performance Pathway option?
In general, APMs are designed to create a more stable and uniform set of MIPS reporting requirements that increase an eligible clinician’s confidence in moving into more risk-bearing arrangements.
For MIPS purposes, an APM Performance Pathway relies on a final MIPS score driven by these 3 performance categories:
- (55% of the performance year 2025 final MIPS score)
- (20% of the performance year 2025 final MIPS score)
- (30% of the performance year 2025 final MIPS score)
To view the 2025 comprehensive list of APMs, visit this resource.
How are clinicians paid under an MVP option?
MVPs were brand-new for performance year 2023. Medicare created this reporting option to provide eligible clinicians with clinically related performance measures that align more closely with their specialty and scope of practice.
“In an MVP, clinicians select from a smaller, more meaningful set of quality measures and improvement activities.”
In an MVP, clinicians select from a smaller, more meaningful set of quality measures and improvement activities. They also report on a set of foundational measures to promote interoperability as well as certain clinician-selected population MACRA MIPS health measures.
In 2025, eligible clinicians can choose from the following:
- Adopting best practices and promoting patient safety within emergency medicine
- Advancing cancer care
- Advancing care for heart disease
- Advancing rheumatology patient care
- Complete ophthalmologic care
- Coordinating stroke care to promote prevention and cultivate positive outcomes
- Dermatological care
- Focusing on women’s health
- Gastroenterology care
- Improving care for lower extremity joint repair
- Optimal care for kidney health
- Optimal care for patients with urologic conditions
- Patient safety and support of positive experiences with anesthesia
- Prevention and treatment of infectious disorders including hepatitis C and HIV
- Pulmonary care
- Quality care for patients with neurological conditions
- Quality care for the treatment of ear, nose, and throat disorders
- Quality care in mental health and substance use disorders
- Rehabilitative support for musculoskeletal care
- Surgical care
- Value in primary care
The good news is that eligible clinicians can report multiple MVPs. For example, an entire internal medicine group can participate as a group to report the ‘value in primary care’ MVP, and a subset of those clinicians can participate as a subgroup to report the ‘advancing care for heart disease’ MVP.
How does MACRA MIPS affect independent practices?
Independent practices may face specific challenges when trying to meet MIPS requirements because they often operate with a smaller budget for training. This means clinicians and medical coders may not be aware of the 2025 performance year MIPS changes, and they may inadvertently overlook quality measure reporting opportunities.
The good news is that there are plenty of free resources available that are tailored to small and independent practices. This includes a newsletter, a "quick start" guide for small practices, and more.
Here are some important MIPS facts for small practices (i.e., practices with 15 or fewer clinicians identified by National Provider Identifier) to note:
- Small practices must report 6 quality measures, including at least 1 outcome measure (or a high-priority measure if no outcome measure is available).
- Small practices will receive 3 points for submitting quality measures without an available benchmark (historical or performance period) as well as an additional 3 points for submitting quality measures that don’t meet the case minimum or data completeness requirements.
- Small practices that submit at least 1 quality measure will continue to earn 6 bonus points.
- Small practices will receive full credit when performing and attesting to 1 activity.
- Small practices are not required to report Promoting Interoperability data.
To see whether your medical practice is considered a ‘small practice,’ visit Participation Lookup (cms.gov).

Is MIPS affected by sequestration?
The Medicare cuts — sometimes referred to as Medicare sequestration cuts — are automatic reductions in Medicare FFS payments resulting from the Budget Control Act of 2011. Note that the MIPS payment adjustment percentage is applied to the Medicare paid amount for covered professional services after calculating deductible and coinsurance amounts but before sequestration.
What is the final rule for the Medicare Clinician Fee Schedule 2025?
Each year, the Medicare Clinician Fee Schedule (MPFS) final rule outlines changes to the merit-based incentive payment program. What are the 2025 quality payment program changes that haven’t already been covered in this article? Here are a few of them:
- For traditional MIPS and MVPs, Medicare will apply an alternative benchmarking methodology to a subset of topped out measures.
- For traditional MIPS and MVPs, Medicare will revise the cost scoring benchmarking methodology starting in the 2024 performance period/2026 MIPS payment year to assess clinician cost of care more appropriately.
- Medicare will change its policy governing multiple data submissions received for the Promoting Interoperability performance category.
- Medicare will remove improvement activity weighting and streamline reporting requirements for the performance category.
- Medicare will finalize minimum criteria for a qualifying data submission in the quality, improvement activities, and promoting interoperability performance categories.
What are the most important MIPS and MACRA deadlines for 2025?
MIPS performance year 2025 began on January 1, 2025. However, there are several other MIPS deadlines to know and bookmark on your calendar. These include the following:
- June 30, 2025: Registration ends for Consumer Assessment of Health care Providers and Systems (CAHPS) for MIPS survey. Note: Registration for the CAHPS for MIPS survey doesn’t technically open until April 1, 2025. This survey may or may not be a required measure depending on how an eligible clinician chooses to participate in MIPS.
- July 5, 2025: This is the last day to start a 180-day performance period for promoting interoperability.
- October 3, 2025: This is the last day to start a 90-day performance period for improvement activities.
- December 1, 2025: Registration ends for MVP. Note: Registration doesn’t open until April 1, 2025.
- December 31, 2025: This is the date on which performance year 2025 ends.
- December 31, 2025: This is the date by which eligible clinicians must apply for a merit-based incentive payment program extreme and uncontrollable circumstances exception for any or all performance categories (when applicable) or a hardship exception to the promoting interoperability performance category (when applicable).
- January 2, 2026: This is when the submission window opens for performance year 2025.
- March 31, 2026: This is when the submission window closes for performance year 2025.
What medical billers need to know about 2025 MIPS updates
The following are some strategies to promote revenue integrity:
- Review clinician documentation. Each quality measure may require specific clinical documentation to justify reporting. Do clinicians provide accurate and complete documentation to support MIPS data? Do all clinicians document the same way for optimal MIPS reporting?
- Audit coded data. Do medical coders capture all relevant data for accurate MIPS reporting? Is there any data that coders omitted that could help improve MIPS performance? For example, are there any modifiers or exclusions that could boost the final MIPS score?
- Review remittance advice. When Medicare makes a MIPS payment adjustment, it may use one of the following codes on the remittance advice:
- Claim adjustment reason code (CARC) 144: Incentive adjustment (e.g., preferred product or service)
- Remittance advice remark code (RARC) N807: Payment adjustment based on MIPS
- Group code CO: Contractual agreement between the payer and payee or a regulatory requirement resulted in an adjustment
- CARC 237: Legislated/regulatory penalty
It’s important to monitor these codes to understand MIPS performance and whether and how MIPS payment adjustments could affect medical practice revenue. This data gives clinicians insight into the types of claims that are adjusted so they can dig into and address any potential root causes.
- Know the deadline to submit data to CMS in 2025 — and don’t miss it. Clinicians can submit data from performance year 2024 between now and March 31, 2025. Missing the deadline could equate to reductions in reimbursements. Sign into the QPP website to start the submission process.
What to do now
CMS plans to sunset traditional MIPS in the future, at which point MVPs will become mandatory. However, it will be a while before this goes into effect. In the meantime, it makes sense to focus on traditional MIPS and choose the right measures for your medical practice. Learn how Tebra can help.
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- Current Version – May 05, 2025Written by: Jean LeeChanges: This article was updated to include the most relevant and up-to-date information available.
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