2021 MIPS - Year 5

Every year, weights are assigned to each of the four components of MIPS and are added together to give you a MIPS final score. In 2021, CMS will use the final score to determine whether to give a positive, neutral, or negative payment adjustment in 2023.

2021 Final Scores and 2023 Payment Adjustments

How to Earn a Positive Payment Adjustment and an Exceptional Performance Bonus

• Decide whether to apply for the hardship exemption to have PI reweighted to Quality, making Quality worth 65% of your overall score
• Earn 15 points by fully participating in the IA component
• Earn up to an additional 50 points through Quality measure reporting
  • Submit 6+ measures with data for a full year (70% of your patients for whom the measure applies, minimum 20 patients per measure, and 1 measure must be an outcome or high priority measure)
• PI Reporting – Earn 25 points by using 2015 CEHRT to report the PI component

Learn about changes to each of the four program components effective in 2019:

• Quality
  (40% of MIPS Score)
  • Report 70% of cases for whom the measure applies
  • 20 case minimum for each measure (does not have to be the same 20 patients for each measure, but there can be overlap)
  • Measures are worth 1-10 points depending on performance compared to the benchmark and practice size
• Promoting Interoperability (PI)
  (25% of MIPS Score)
  • Must attest to the security risk assessment
  • Must report measures or take the exclusion, noting your reason
  • Hospital-based clinicians (those with 75% or more of their billing from their hospital), PAs, and NPs are exempt from PI and will have this category automatically re-weighted to Quality (making Quality 65% of the score)
  • Small practices can apply for a hardship exemption to reweight PI to Quality- visit qpp.cms.gov
• Improvement Activities (IA)
  (15% of MIPS Score)
  • Simple attestation to various quality improvement activities
  • Must have documentation somewhere in practice for QCDR audit or in case of CMS random audit
• Cost
  (20% of MIPS Score)
  • No reporting, this is done via claims
  • Read more about how cost measures are structured here

Ready to Report?

ASPS has developed a Qualified Clinical Data Registry (QCDR) to assist with all your MIPS reporting needs.

• 22 MIPS measures and 13 QCDR (non-MIPS) plastic surgery specific quality measures
  • Plastic surgery measures for reconstruction after skin cancer resection, breast reconstruction, and rhinoplasty
• Can report all 3 components (Cost component determined by claims)
• Accepts manual data entry, or integrate your EMR

New to MIPS reporting? Contact Caryn Davidson, Quality Projects Manager at quality@plasticsurgery.org or (847) 228-3349 to set up a FREE consultation for your MIPS reporting needs. Please contact Caryn as soon as possible - do not wait!