Claimocity Claims
MIPS Reporting:
A Complete Guide for Providers and Billing Teams
MIPS reporting is how most clinicians who bill Medicare Part B prove the quality and value of their care to CMS. CMS turns that data into a final score from 0 to 100, and the score sets a payment adjustment on your Medicare Part B claims two years later. A low score can cut those payments by as much as 9%.
The stakes are higher in 2027. Under the CY 2027 Physician Fee Schedule final rule, Medicare will pay hospitalists about 2.3% to 4.1% less per visit for core inpatient codes, before MIPS is applied. A MIPS penalty comes off that lower rate. A positive adjustment helps offset it.
The program has a lot of moving parts, and most of the official guidance is written with outpatient clinics in mind. That leaves hospitalists, inpatient specialists, and the billing teams behind them working out which rules actually apply. This guide explains how MIPS reporting fits together from start to finish with an emphasis on inpatient care.
What Is MIPS Reporting?
MIPS stands for the Merit-based Incentive Payment System. It’s one of two tracks in Medicare’s Quality Payment Program (QPP), which Congress created through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The other track is for clinicians who participate in Advanced Alternative Payment Models (APMs).
When people talk about MIPS in healthcare, they usually mean the annual reporting cycle that eligible clinicians go through. It works on a two-year lag:
- Performance year. You collect data from January 1 through December 31.
- Submission. You submit that data to CMS early the following year.
- Payment year. CMS applies your payment adjustment to Medicare Part B claims the year after submission.
Your 2026 performance, for example, sets your 2028 Medicare Part B payments. That lag is why decisions made early in the year carry so much weight. By the time you see your score, the payment impact is already locked in.
MIPS reporting vs. MIPS measures. The two terms get used interchangeably, but they mean different things. “MIPS measures” usually refers to the Quality measures you select and report. MIPS reporting covers everything you submit across all four performance categories. If you’re trying to decide which Quality measures to report, start with our guide to MIPS Quality measures.
Who Has to Report to MIPS?
You’re required to participate in MIPS if you’re an eligible clinician type, you’re enrolled in Medicare, and you exceed the low-volume threshold. Eligible clinician types include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, along with several therapy and behavioral health professions.
The low-volume threshold has three parts. You’re excluded from MIPS if any one of these is true during the determination period:
- You billed $90,000 or less in Medicare Part B allowed charges for covered professional services.
- You provided care to 200 or fewer Medicare Part B patients.
- You provided 200 or fewer covered professional services to Medicare Part B patients.
If you exceed all three, you’re required to report. If you exceed one or two, you can choose to opt in. Clinicians in their first year of Medicare enrollment and Qualifying APM Participants are also excluded.
CMS checks eligibility using two 12-month segments of claims data, each running October 1 through September 30. You can confirm your status any time by entering your NPI in the QPP Participation Status Tool. For a full walkthrough, see how CMS determines MIPS eligibility.
For hospital-based clinicians: Full-time hospitalists typically clear the low-volume threshold. The more important question is how your eligibility is tied to your billing. CMS evaluates each combination of NPI and Tax Identification Number (TIN) separately. If you bill under more than one TIN, such as a hospitalist group and a separate locum arrangement, you may be eligible under one and excluded under another.
MIPS Reporting Requirements
MIPS scores you across four performance categories. You submit data for two of them, attest to one, and CMS calculates the fourth from your claims. Here are the core MIPS reporting requirements under standard scoring.
| Category | Default weight | What you submit | Minimum for credit |
|---|---|---|---|
| Quality | 30% | Data on six measures, including at least one MIPS core measure if one applies to you (small practices are exempt) | Full calendar year, with data on at least 75% of eligible patients for each measure |
| Cost | 30% | Nothing. CMS calculates Cost from Medicare claims | You must meet each measure’s case minimum to be scored |
| Improvement Activities | 15% | An attestation for each activity you performed | Two activities (one for MVP reporters and for small, rural, HPSA, and non-patient-facing clinicians), each performed for at least 90 consecutive days |
| Promoting Interoperability | 25% | Measures from certified EHR technology (CEHRT), plus required attestations | At least 180 consecutive days using CEHRT, with all required attestations completed, including the SAFER Guides measure |
A few details trip people up every year:
- Data completeness. The 75% threshold applies to each Quality measure. Reporting on a handpicked subset of patients fails it, even if your performance rate looks strong.
- Fewer than six measures. If fewer than six measures apply to your practice, you report every one that does. CMS can then adjust your scoring through its Eligible Measure Applicability (EMA) process.
- Required PI attestations. Answering “no” on a required attestation, such as the SAFER Guides measure, zeroes out the entire Promoting Interoperability category. CMS removed the Security Risk Analysis measure starting with the 2027 performance year, but it still applies to 2026 data.
- Group Improvement Activities. When a group attests to an activity, at least 50% of the clinicians billing under the TIN must have performed it during the same 90-day period.
The Four MIPS Performance Categories
Each category measures something different, and each has its own scoring rules. Here’s what you need to know about each one before you go deeper.
Quality
Quality measures track clinical processes and outcomes, such as whether eligible patients received a recommended screening or how well a condition was controlled. CMS compares your performance rate on each measure to a national benchmark and awards up to 10 points per measure. Measure selection matters more here than anywhere else in MIPS, because a measure with a tough benchmark can cap your score even when your care is excellent. Learn how to choose measures in our guide to MIPS Quality measures.
Cost
Cost uses Medicare claims to measure the resources tied to your patients’ care, including total per capita costs and episode-based measures for specific conditions and procedures. You don’t submit anything. CMS attributes patients and episodes to you based on the services you bill. You can’t influence Cost through reporting, but complete documentation of patient complexity supports the risk adjustment CMS applies.
Improvement Activities
Improvement Activities recognize work that improves care delivery, such as care coordination, patient safety programs, and behavioral health integration. CMS publishes an inventory of activities each year, and most practices can find activities that match work they already do. Keep records that show each activity ran for at least 90 consecutive days, since CMS can request documentation. Our MIPS Improvement Activities guide covers the inventory and how to choose.
Promoting Interoperability
Promoting Interoperability (PI) measures how you use certified EHR technology for e-prescribing, health information exchange, patient access to records, and public health reporting. Many hospital-based clinicians never report this category, because CMS automatically reweights it for them. More on that below. For the measures and scoring, see Promoting Interoperability reporting and scoring.
How MIPS Scoring Works
CMS scores each category, multiplies each score by the category’s weight, and adds the results into a final score from 0 to 100. When a category can’t be scored, CMS reweights it and moves its points to other categories. The two most common reweighting scenarios look like this:
| Scenario | Quality | Cost | Improvement Activities | Promoting Interoperability |
|---|---|---|---|---|
| Standard scoring | 30% | 30% | 15% | 25% |
| PI reweighted (common for hospital-based clinicians) | 55% | 30% | 15% | 0% |
| PI reweighted, small practice | 40% | 30% | 30% | 0% |
That middle row explains why Quality carries so much weight for hospitalists. When PI drops out, Quality becomes more than half of the final score. For a full breakdown of points, bonuses, and benchmarks, read how MIPS scoring works.
How Your MIPS Score Affects Payment
Your final score is compared to a performance threshold that CMS sets each year. The threshold is set at 75 points through the 2028 performance year. Here’s how scores translate into payment adjustments:
| Final score | Payment adjustment two years later |
|---|---|
| 0 to 25% of the threshold (0 to 18.75 points) | Maximum negative adjustment of 9% |
| Above 18.75 and below 75 points | Negative adjustment on a sliding scale between 9% and 0% |
| Exactly 75 points | No adjustment |
| Above 75 points | Positive adjustment on a sliding scale |
The penalty side is predictable. The reward side isn’t. MIPS is budget neutral, so CMS funds positive adjustments with the penalties collected from low scorers. Positive adjustments land well below the 9% maximum. For the 2027 performance year, CMS projects the largest positive adjustment at about 1.34%. For most practices, the biggest financial stake in MIPS is reaching at least 75 points to avoid a cut. To set a realistic target for your practice, see what counts as a good MIPS score.
How to Report MIPS: Three Decisions That Shape Your Score
Before the performance year starts, every practice makes three choices. They’re easy to change before January and hard to undo after.
1. Your participation level
- Individual. Data is tied to one clinician’s NPI under a TIN. You control your own score, but each clinician carries their own reporting work.
- Group. Everyone billing under the same TIN reports together and shares one score. Group reporting cuts administrative work and is common for hospitalist groups. The tradeoff is that one weak performer affects everyone.
- Subgroup. Available only for MIPS Value Pathways. Lets a multispecialty group split into clinically related teams.
- APM Entity. Available to clinicians in a MIPS APM, such as an accountable care organization.
If you report as an individual and your group also reports, CMS uses the higher of the two scores for each clinician.
2. Your reporting framework
- Traditional MIPS. You choose your own Quality measures and Improvement Activities from the full inventories.
- MIPS Value Pathways (MVPs). CMS has finalized making MVPs the only way to report MIPS starting with the 2031 performance year. Traditional MIPS remains available through 2030.
- APM Performance Pathway (APP). A fixed measure set for clinicians in MIPS APMs.
The right framework depends on your specialty. If an MVP fits your patient population, it can narrow your choices to the measures most relevant to your work.
3. Your collection type and submitter
Quality measures can be collected as electronic clinical quality measures (eCQMs) pulled from your EHR, MIPS clinical quality measures (CQMs), or Qualified Clinical Data Registry (QCDR) measures. Small practices can also report some measures through Medicare Part B claims.
Someone then has to submit the data. Most practices use one of three routes:
- A qualified registry or QCDR. The registry validates your data, flags gaps before submission, and submits on your behalf.
- Data from your EHR. Your EHR can export eCQM data for you or your registry to submit. This works well if your EHR is certified for the measures you chose and your data quality is reliable.
- Direct submission. You upload files or attest manually in the QPP portal. This gives you the most control and the most work.
Whichever route you choose, confirm early that it supports every measure you plan to report.
MIPS for Hospital-Based and Facility-Based Clinicians
If you practice mostly in hospitals, two special statuses can change how much you report. They sound similar, but they do different things.
Hospital-based status reweights Promoting Interoperability. You’re hospital-based if you furnish 75% or more of your covered professional services in inpatient, on-campus outpatient, off-campus outpatient, or emergency department settings. A group qualifies when more than 75% of its clinicians are hospital-based. CMS reweights PI to 0% automatically, so you don’t report it. The logic is simple: you don’t control your hospital’s EHR.
Facility-based status can replace your Quality and Cost scores. You’re facility-based if you furnish 75% or more of your covered professional services in inpatient, on-campus outpatient, or emergency department settings, with at least one service in an inpatient or ED setting. A group qualifies when 75% or more of its clinicians are facility-based. CMS then scores your Quality and Cost categories using your hospital’s performance in the Hospital Value-Based Purchasing (VBP) Program.
Here’s what facility-based scoring does and doesn’t cover:
- Individuals don’t have to submit anything for facility-based scoring to apply.
- Groups must submit data in Improvement Activities or Promoting Interoperability to be scored as a facility-based group.
- Improvement Activities still count. Facility-based scoring doesn’t fill that 15%. If you skip it, those points are gone.
- You don’t choose the higher score manually. If you also submit Quality data, CMS automatically uses whichever approach gives you the higher final score.
- Your score is tied to your hospital. CMS assigns you to the facility where you treated the most Medicare patients. If that hospital performs poorly in VBP, so does your Quality score.
Specialists who split time between the hospital and a clinic, such as orthopedic surgeons or infectious disease physicians, often fall below the 75% line. In that case, the standard reporting requirements apply.
MVPs will change this picture. CMS finalized a Hospitalist MVP starting with the 2027 performance year, and MVPs become the only way to report MIPS in 2031. How facility-based scoring fits into that shift will matter for every hospitalist group. We cover the latest in what’s changing in MIPS this year.
The MIPS Reporting Timeline
MIPS runs on a predictable annual cycle:
- Before January 1. Confirm eligibility and special statuses, choose your participation level and framework, and finalize your measures.
- January 1 to December 31. The performance year. Quality and Cost cover the full year. Improvement Activities need at least 90 consecutive days, and Promoting Interoperability needs at least 180.
- Early the following year. The submission window opens in January and typically closes March 31.
- Summer. CMS releases final scores and feedback, followed by a short window to request a targeted review if you believe there’s an error.
- January 1, two years after the performance year. Your payment adjustment takes effect on Medicare Part B claims for the full year.
CMS publishes rule changes each fall, usually in early November, in the Physician Fee Schedule final rule. Those changes take effect for the next performance year, which leaves practices about two months to adjust. We break them down each year in what’s changing in MIPS this year.
Common MIPS Reporting Mistakes
- Assuming facility-based scoring covers everything. It covers Quality and Cost. Improvement Activities still need an attestation.
- Falling short on data completeness. A strong performance rate earns nothing if the measure doesn’t meet the 75% completeness threshold.
- Picking measures by habit. Benchmarks shift every year. A measure that scored well last year may cap your points this year.
- Missing documentation. CMS can audit Improvement Activities and Quality data. If you can’t show your work, you can lose the credit.
- Waiting until the fourth quarter. By then, most of the performance year is gone and there’s little room to fix a gap.
Simplify MIPS Reporting with Claimocity
MIPS reporting shouldn’t be a second job. For most practices, it means tracking measures across facilities, chasing documentation, and piecing data together right before the deadline.
Claimocity builds MIPS into the workflow inpatient providers already use. Our integrated reporting tools track the measures that matter to you, apply hospital-based exemptions automatically, and organize your data in real time. You document in your clinical notes, and Claimocity captures the MIPS data alongside your billable events, with no extra logins and no year-end scramble. When it’s time to submit, our registry partner, Patient360, handles submission to CMS.
- See where you stand on every measure throughout the year
- Catch data completeness gaps before they cost you points
- Stay audit-ready without extra paperwork
See how Claimocity’s MIPS reporting tools give you your time back.
MIPS Reporting FAQs
What is MIPS reporting?
MIPS reporting is the annual process of submitting performance data to CMS under the Merit-based Incentive Payment System. CMS uses that data to calculate a final score that raises, lowers, or holds steady your Medicare Part B payments two years later.
Is MIPS reporting mandatory?
It is for eligible clinicians who exceed all three parts of the low-volume threshold. If you’re required to participate and don’t report, you’ll likely receive the maximum negative payment adjustment.
Do hospitalists have to report MIPS?
Most hospitalists are eligible, but many report less than outpatient clinicians do. Hospital-based clinicians don’t report Promoting Interoperability, and facility-based clinicians can have Quality and Cost scored from their hospital’s performance. Improvement Activities still need to be reported.
When is the MIPS reporting deadline?
The submission window opens in early January after the performance year and typically closes March 31. CMS confirms the exact dates each year on the QPP website.
What's the difference between MIPS and MVPs?
MVPs are a reporting framework within MIPS. Instead of choosing from the full measure inventory, you report a smaller set of measures and activities tied to a specialty or condition. Starting with the 2031 performance year, MVPs will be the only way to report MIPS.
Sources
- 42 CFR 414.1305, definitions
- 42 CFR 414.1320, performance periods
- 42 CFR 414.1335, Quality submission criteria
- 42 CFR 414.1340, data completeness
- 42 CFR 414.1360, Improvement Activities
- 42 CFR 414.1380, scoring and facility-based measurement
- CY 2027 Physician Fee Schedule final rule, CMS-1848-F, 91 FR 70992 (November 9, 2026)
