MIPS Year 5: Your Questions Answered

Read our MIPS Year 5 infographic for answers to all of your questions about year five of the Quality Payment Program (QPP), including key changes for 2021.
Clinical Infographic Value-Based care

In light of the many challenges clinicians faced in 2020 because of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) has made some additional changes to its Merit-based Incentive Payment System (MIPS) for the upcoming year.

Even as you keep your primary focus on the health and safety of your patients and staff during the pandemic, it’s important to maintain your familiarity with MIPS guidelines, both to avoid penalties and to continue to support your practice’s financial health.

The following infographic captures important takeaways for Year 5 of MIPS, including changes to the program for 2021, eligibility criteria, a breakdown of how scores are calculated and what’s at stake for the future. You also will see that many MIPS measures, such as breast- cancer screening, colorectal-cancer screening, fall-risk assessment and many others, can be automatically captured during the intake process.

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MIPS Year 5: Your Questions Answered

CMS issued the final rule for the fifth year of its Quality Payment Program (QPP), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

CMS states that Year 5 the QPP is designed to:

  • Ease the burden on MIPS-eligible organizations and ACOs due to the extreme circumstances of COVID-19
  • Expand coverage of telehealth services to accommodate rise in virtual visits Utilize more meaningful, outcomes-based measures

Clinicians may choose between two tracks under the QPP:

  • MIPS

The Merit-based Incentive Payment System allows clinicians to earn performance-based payment adjustments based on the services they provide to their Medicare patients.

  • Advanced Alternative Payment Models (APMs)

Clinicians who receive at least 50% of their Medicare Part B payments or see at least 35% of their Medicare patients through an Advanced APM entity qualify to be APM participants.

CMS estimates that between 196,000 and 252,000 eligible clinicians may qualify for the APM track in 2021 for payment year 2023.


CMS estimates that approximately 890,742 clinicians will be eligible for MIPS in 2021, which will determine MIPS payment adjustments for 2023. That’s up from approximately 879,966 eligible clinicians in 2020.

In Year 5, MIPS-eligible clinician types remain the same as in 2020:

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists
  • Physical Therapists
  • Occupational Therapists
  • Clinical Psychologists
  • Qualified Speech-Language Pathologists
  • Qualified Audiologists
  • Registered Dieticians or Nutrition Professionals

Clinicians are NOT eligible for Year 5 of MIPS if they:

  • Are not a MIPS-eligible clinician type
  • Enrolled in Medicare after Jan. 1, 2021
  • Meet any of the following low-volume threshold criteria:
    • Bill less than $90,000 for Medicare Part B-allowed services
    • See fewer than 200 Medicare Part B patients
    • Provide 200 or fewer covered professional services under the Physician Fee Schedule

CMS estimates that approximately 734,715 clinicians will not be eligible for MIPS in 2021.


  • The Quality performance category weight was reduced from 45% to 40%, and the Cost performance category weight increased from 15% to 20%. Both categories will be weighted at 30% in 2022.
  • CMS increased the minimum threshold to 60 points, (up from 45 points in 2020), for the new performance year. This means clinicians must achieve at least 60 MIPS points to avoid a penalty.
  • CMS added telehealth services directly applicable to existing episode-based cost measures and a Total Per Capita Costs (TPCC) measure within the Cost performance category.
  • CMS will delay the MIPS Value Pathways reporting framework until the 2022 performance period or later.



  • Quality: 45%
  • Promoting Interoperability (formerly Advancing Care Information): 25%
  • Improvement Activities: 15%
  • Cost: 15%


  • Quality: 45%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
  • Cost: 15%


  • Quality: 40%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
  • Cost: 20%

In reporting year 2021, the possible adjustment for 2023 payments remains the same as in reporting year 2020, at +/- 9%.

CMS estimates there will be $458 million in penalties and incentives redistributed in 2023, PLUS an extra pool of $500 million to be paid out to exceptional performers whose composite scores meet or exceed 85.

  • 2020: +/- 5%
  • 2021: +/- 7%
  • 2022: +/- 9%
  • 2023: +/- 9%

Because the MIPS program is budget-neutral, actual incentive payments are often below the top threshold. For instance, providers who achieved the maximum MIPS score in 2019 will see their 2021 payments go up by +1.79%, including both positive and exceptional performance adjustments. However, CMS reports that maximum incentives are expected to increase as the program’s penalties increase. CMS projects the maximum bonus in 2023, based on 2021 data, will be 5.3%.

Performance Thresholds

Clinicians whose composite score falls between 0 and 60 will see their 2023 payments docked by as much as -9%.

Clinicians whose composite score falls between 60 and 85 could see incentive payments as high as 9%.

Clinicians whose composite score falls between 85 and 100 will be eligible for additional bonus payments.

  • 2018 performance threshold: 15
  • 2019 performance threshold: 30
  • 2020 performance threshold: 45
  • 2021 performance threshold: 60


JAN 1, 2021: Performance year 2021 begins

DEC 31, 2021: Performance year 2021 ends

JAN 3, 2022: Submission window opens for PY 2021

JULY 2022: Performance feedback available for 2021

JAN 1, 2023: Performance year 2021 payment adjustments go into effect


Data for many MIPS measures can be captured automatically during the intake process, including:

  • Depression Screening
  • Tobacco-Use Screening
  • Fall-Risk Assessment
  • Documentation of Current Medications
  • Colorectal-Cancer Screening
  • Breast-Cancer Screening
  • Unhealthy Alcohol-Use Screening
  • Pneumococcal Vaccination Status for Older Adults
  • Cervical-Cancer Screening
  • Functional Status Assessment for Total Knee Replacement
  • Evaluation or Interview for Risk of Opioid Misuse

and more!

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