Here’s How MIPS Participation Eligibility Shrinks and Grows in 2019

MIPS eligibility 2019

We’re in the third year of the Quality Payment Program (QPP), which includes the Merit-based Incentive Payment System (MIPS). The QPP is connected to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Because MIPS may result in Medicare payment adjustments up or down, knowing whether you’re required to participate is an essential first step. Here’s what the MIPS participation eligibility criteria look like in 2019. (For info on some terminology changes in MIPS 2019, read this blog post.)

See How the List of Eligible Clinician Types Grows

For the 2019 performance year, the Medicare final rule expanded the list of MIPS eligible clinicians by adding these:

  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered dieticians or nutrition professionals.

These clinicians also are eligible for participation:

  • Physicians: MD, DO, DDS, DMD, DPM, OD, and chiropractors (for certain treatment, the latter must be legally authorized to practice by the state where the service occurs)
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists.

For group participation, the group must include at least one of the clinician types from the bullets lists above.

But Plenty of Folks Are Excluded From MIPS, Too

To be part of the MIPS track of QPP, you need to exceed all three low-volume criteria:

  • Bill more than $90,000 per year in allowed charges for covered Medicare Physician Fee Schedule professional services, AND
  • Provide covered professional services to more than 200 Medicare beneficiaries in a year, AND
  • Furnish more than 200 covered MPFS professional services.

If you don’t exceed all three for 2019, you are excluded.

But don’t miss this: You may opt-in to MIPS if you meet or exceed one or two of the MIPS low-volume threshold criteria.

More exclusion rules: You’re excluded from MIPS in 2019 if you meet any one of these conditions:

  • You are newly enrolled in Medicare
  • You participate in an Advanced Alternative Payment Model (APM) and are a Qualifying APM Participant (QP)
  • You participate in an Advanced APM, are a partial QP, and don’t choose to participate in MIPS.

Remember: When you read through the final rule for more MIPS information, don’t just look for “2019.” Why? There are references to both the 2019 “performance year” (meaning this year when you are performing services) and the 2019 “payment year” (referring to you getting payment adjustments in 2019 based on 2017 performance). So for MIPS information related to services you perform in 2019, look for 2019 performance year.

You also can check out the CMS QPP Resource Library for official information.

What About You?

Do the changes for 2019 MIPS eligibility criteria affect you? Do you think the changes to MIPS for 2019 are helpful?



Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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