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2024 MIPS and MACRA updates: A guide for clinicians and medical billers

You can submit data from performance year 2023 between now and April 15, 2024. Missing the deadline could equate to reductions in reimbursements.

MACRA MIPS updates guide

At a Glance

  • Medicare has transitioned from fee-for-service to a value-based payment model under the 2015 MACRA law, rewarding clinicians for quality rather than quantity of care.
  • The Quality Payment Program under MACRA introduces merit-based incentive payment systems (MIPS) and advanced alternative payment models (APMs) to enhance care quality and patient outcomes.
  • MIPS eligibility and participation are mandatory for many providers, and performance affects future Medicare payments based on quality, cost efficiency, and use of certified EHR technology.

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.

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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 work 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 and punish clinicians who don’t meet performance standards with reduced payments.

What does MACRA mean for patients and clinicians?

Patients benefit from 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. 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.

Understanding MIPS in healthcare: how it relates to MACRA

MIPS in healthcare, formally known as the Merit-Based Incentive Payment System, is a program established by Medicare to link physician reimbursement to quality and cost-effective care. Clinicians participating in MIPS can earn payment bonuses or avoid penalties based on their performance across four key categories: quality, cost, promoting interoperability, and improvement activities. While MACRA (Medicare Access and CHIP Reauthorization Act) offers alternative pathways to achieve similar goals., MIPS remains a crucial option for many healthcare providers.

In 2024, 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.

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 must then participate in MIPS.

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 in healthcare?

The 4 performance categories that potentially drive the final MIPS score are: 

  1. 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.
  2. Promoting interoperability. Measures in this performance category denote patient engagement and the exchange of health information using certified electronic health record (EHR) technology.
  3. Practice improvement activities. Measures in this performance category reflect how well a clinician improves care processes, enhances patient engagement, and increases access to care.
  4. 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).

4 components of MIPS

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 2024 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%

However, it’s important to note that there is no immediate impact of MIPS data on payment. In fact, there’s actually a 2-year delay. This means the data that eligible clinicians submit during performance year 2024 doesn’t affect payments until 2026. Likewise, current-day payments in 2024 are based on a clinician’s MIPS score from performance year 2022. 

The MIPS performance year begins on January 1. The end date depends on the specific MIPS category. For quality and cost, the performance year ends on December 31 each year. For promoting 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 final MIPS score is based on the following performance categories:

  • Clinical quality (30% of the performance year 2024 final traditional MIPS score). In 2024, there are 201 different measures, each of which has a performance threshold. Some examples of these clinical quality measures include advance care planning, breast cancer screening, controlling high blood pressure, and more.
  • Promoting interoperability (25% of the performance year 2024 final traditional MIPS score). In 2024, there are 38 different measures, each of which has a performance threshold. Some examples of these measures include clinical data registry reporting through the EHR, eRx, giving patients access to their health information in the EHR, and more.
  • Practice improvement activities (15% of the performance year 2024 final traditional MIPS score). In 2024, there are 106 different measures, each of which has a performance threshold. Some examples of these measures include anticoagulation management improvements, care transition documentation practice improvements, completing collaborative care management training programs, and more. 
  • Cost (30% of the performance year 2024 final traditional MIPS score). 

If your practice needs support with traditional MIPS, learn more about how Tebra can help.

How are clinicians paid under the APM Performance Pathway option?

In general, APMs 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:

To review the 2024 comprehensive list of APMs, click here and then scroll to the link at the bottom of the page.

How are clinicians paid under an MVP option?

MVPs were new for performance year 2023. They provide eligible clinicians with clinically related performance measures that align more closely with their specialty and scope. 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 2024, eligible clinicians can choose from the following 16 MVPs:

  • Adopting best practices and promoting patient safety within emergency medicine
  • Advancing cancer care
  • Advancing care for heart disease
  • Advancing rheumatology patient care
  • Coordinating stroke care to promote prevention and cultivate positive outcomes
  • Focusing on women’s health*
  • Improving care for lower extremity joint repair
  • Optimal care for kidney health
  • Optimal care for patients with episodic neurological conditions
  • Patient safety and support of positive experiences with anesthesia
  • Prevention and treatment of infectious disorders including hepatitis C and HIV*
  • 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*
  • Supportive care for neurodegenerative conditions
  • Value in primary care

*Newly finalized for 2024. (Note that in 2024, the “promoting wellness” MVP and “optimizing chronic disease management” MVP are combined as “value in primary care.”)

MIPS 16 MVPs 2024

For example, the “women’s health” MVP targets gynecologists, obstetricians, urogynecologists, and certified nurse midwives, while the “advancing cancer care” MVP targets oncologists and hematologists.

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 2024 MIPS changes, and they may inadvertently overlook MACRA quality measure reporting opportunities. The good news is that there are plenty of free resources tailored to small and independent practices. These include a newsletter, a data submission checklist for the 2023 performance year, 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. 
  • Small practices will receive 3 points for submitting quality measures without an available benchmark (historical or performance period) as well as quality measures that don’t meet the case minimum or data completeness requirements. 
  • Small practices that submit at least one quality measure will continue to earn 6 bonus points. 
  • Small practices will receive twice the score for each improvement activity. For example, activities valued at 10 points will yield 20. Those valued at 20 points will yield 40.
  • Small practices are not required to report promoting interoperability data.

To see whether your medical practice is considered a small practice, visit Participation Lookup (

MIPS facts for small practices

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. In 2024, there will be a 3.37% payment cut. 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 Medicare Clinician Fee Schedule 2024?

Each year, the Medicare Clinician Fee Schedule (MPFS) final rule outlines changes to the merit-based incentive payment program. What are the CMS changes for 2024 that haven’t already been covered in this article? Here’s a broad overview:

  • There are a total of 198 quality measures for the 2024 performance period, including:
    • 11 new quality measures (e.g., ambulatory palliative care patients’ experience of feeling heard and understood, connection to community service provider, reduction in suicidal ideation or behavior symptoms, and more)
    • Removal of 11 quality measures
    • Partial removal of three measures (retained for MVP use only)
    • Substantive changes to 59 existing quality measures
  • There are 106 practice improvement activities in the MIPS inventory, including 5 new activities: improving practice capacity for HIV prevention services, practice-wide quality improvement in MIPS Value Pathways, use of computable guidelines and clinical decision support to improve adherence for cervical cancer screening and management guidelines, behavioral/mental health and substance use screening and referral for pregnant and postpartum women, and behavioral/mental health and substance use screening and referral for older adults. Three existing improvement activities were removed for 2024.
  • The performance period for the practice improvement category increased from a minimum of 90 continuous days to a minimum of 180 continuous days within the calendar year.
  • There are a total of 29 cost measures available for CMS to calculate a cost score, including these 5 new episode-based cost measures:
    • Depression (chronic condition) 
    • Emergency medicine (care provided in an emergency department setting)
    • Heart failure (chronic condition)
    • Low back pain (chronic condition)
    • Psychoses and related conditions (acute inpatient medical condition)

What are the most important MIPS and MACRA deadlines for 2024?

MIPS performance year 2024 began on January 1, 2024. However, there are several other important MIPS deadlines to know and mark on your calendar. These include the following:

  • July 1, 2024: 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, 2024. This survey may or may not be a required measure depending on how an eligible clinician chooses to participate in MIPS.
  • July 5, 2024: The last day to start a 180-day performance period for promoting interoperability.
  • October 3, 2024: The last day to start a 90-day performance period for improvement activities. 
  • December 2, 2024: Registration ends for MIPS Value Pathways. Note: registration doesn’t open until April 1, 2024. 
  • December 31, 2024: Performance year 2024 ends.
  • January 2, 2025: 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, 2025: The submission window opens for performance year 2024.
  • March 31, 2025: The submission window closes for performance year 2024.
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What medical billers need to know about 2024 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. As a medical coder, did you capture all relevant data (including updated ICD-10-CM diagnosis codes, CPT codes, and HCPCS codes) 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 2024 — and don’t miss it. Clinicians can submit data from performance year 2023 between now and April 15, 2024. Although the original deadline was April 1, 2024, CMS has extended the 2023 MIPS data submission deadline until April 15 due to ongoing concerns with the impact the Change Healthcare cybersecurity attack is having on physician practices.

what medical billers need to know about 2024 MIPS updates

What to do now

CMS plans to sunset traditional MIPS in the future, at which point MVPs will become mandatory. It will be a while before this goes into effect, however; 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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Lisa Eramo, freelance healthcare writer

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

Reviewed by

Beth Onofri

Beth Onofri is a regulatory expert in the healthcare industry. She has been with Kareo (now Tebra) since September 2012, and has worked in healthcare for over 25 years. She has a Masters of Science in education (MSEd), and certifications in ISO auditing, adult education, and Patient-Centered Medical Home (PCMH).

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