Glossary · Reimbursement

MIPS (Merit-based Incentive Payment System)

MIPS (Merit-based Incentive Payment System) is one of two participation tracks under CMS's Quality Payment Program (QPP), in which eligible clinicians earn a composite performance score across four categories that directly adjusts their Medicare Part B reimbursement—up or down—two years later.

Verified May 8, 2026 · 6 sources ↓

Drawn from CMSMdinteractiveAAOSAMA

Definition

Source · Editorial summary grounded in 6 cited references ↓

MIPS was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and replaced three legacy programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program. Under MIPS, a clinician's performance is measured across four weighted categories: Quality (30% of the final score), Cost (30%), Promoting Interoperability (25%), and Improvement Activities (15%). These weights shift annually by CMS rule, so orthopedic practices must verify current allocations each performance year. Data collected or submitted during a given performance year determines a composite MIPS score on a 0–100 scale. That score is compared against a CMS-set performance threshold—75 points for the 2024 performance year—and the resulting payment adjustment (positive, neutral, or negative) applies to Medicare Part B claims two years later, meaning 2024 performance translates to 2026 payment rates.

For orthopedic surgeons, MIPS participation requires selecting at least six Quality measures, including at least one outcome or high-priority measure, and reporting them across 100% of denominator-eligible encounters for the full performance year. CMS publishes an orthopedic-specific measure set to help surgeons identify clinically relevant options. Failing to meet the 75-point threshold exposes a practice to a negative payment adjustment that, for the 2026 payment year, could reach –9% of all Medicare Part B payments. Exceptional performers above the exceptional performance threshold can qualify for additional positive adjustments scaled by an adjustment factor designed to keep the program budget-neutral.

CMS publishes each eligible clinician's MIPS score and category-level scores publicly through its Physician Compare platform, making performance history a permanent, visible part of a clinician's professional record. That reputational dimension persists across practice changes—scores follow the individual clinician's NPI, not the group.

Why it matters

A missed or low MIPS score is not a paperwork inconvenience—it is a durable, two-year revenue penalty applied to every Medicare Part B claim the practice submits. For a high-volume orthopedic practice, a –9% adjustment on Part B volume can represent tens of thousands of dollars in lost reimbursement, and the score is publicly searchable, affecting referral relationships and payer contract negotiations. Conversely, a well-optimized MIPS submission can yield a positive adjustment and, when scores are exceptional, an additional incentive payment. Because the financial and reputational impact attaches to the individual clinician's NPI, overlooking MIPS—or submitting incomplete data—carries lasting consequences that survive practice or employer changes.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

  • Submitting fewer than six Quality measures or omitting the required outcome or high-priority measure, which caps the Quality score regardless of measure-level performance.
  • Reporting Quality measures on only Medicare encounters rather than all payer encounters across the full year, causing the denominator to fall below the 100% required threshold and lowering benchmark-adjusted scores.
  • Missing the annual performance threshold update: the threshold rose to 75 points for 2024, and practices that plan around a prior year's threshold inadvertently accept a negative adjustment.
  • Neglecting to verify MIPS eligibility status each year via the QPP Participation Status lookup tool—volume or billing-threshold changes can shift a clinician from required to exempt or vice versa.
  • Treating Promoting Interoperability as automatic when the practice's EHR has not been updated to the 2015 Cures Edition certified technology, which disqualifies the category and can force score reweighting that harms the final composite.
  • Assuming group reporting eliminates individual risk—each clinician's historical scores remain tied to their NPI and are publicly reported even if the group submits collectively.
  • Waiting until year-end to audit measure capture instead of running mid-year reviews, leaving no time to correct data gaps before the submission deadline.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01Who is required to participate in MIPS?
Clinicians who bill Medicare Part B above CMS's low-volume threshold—currently more than $90,000 in Part B charges and more than 200 Medicare patients in a 12-month determination period—are generally required to participate. Clinicians below those thresholds, those in their first year of Medicare billing, or those participating in a qualifying Alternative Payment Model (APM) may be exempt. Check your QPP Participation Status at qpp.cms.gov annually, because eligibility can change.
02What happens if an orthopedic surgeon does not submit any MIPS data?
Submitting no data at all results in the maximum negative payment adjustment—currently –9% of all Medicare Part B payments for the applicable payment year. Because that adjustment applies to every Part B claim, not just orthopedic claims, a no-submission outcome is the single costliest MIPS error a practice can make.
03What MIPS Quality measures are most relevant to orthopedic surgeons?
CMS publishes an orthopedic specialty measure set that includes measures covering functional status outcomes for total hip and knee arthroplasty, antibiotic stewardship for surgical site infection prevention, and osteoporosis management. At least one selected measure must be an outcome or high-priority measure. MDinteractive and the AAOS Coding Coverage & Reimbursement Committee maintain annually updated lists aligned to the current performance year.
04How is the MIPS payment adjustment calculated?
CMS compares a clinician's composite MIPS score to the performance threshold (75 points for the 2024 performance year). Scores at or above the threshold receive a neutral or positive adjustment; scores below it trigger a negative adjustment scaling up to –9%. High scorers above the exceptional performance threshold qualify for an additional positive adjustment multiplied by a budget-neutrality factor. The adjustment applies two years after the performance year—so 2024 data affects 2026 Medicare payments.
05Does a clinician's MIPS score carry over when they join a new practice?
Yes. MIPS scores are tied to the individual clinician's NPI, not to the group or practice TIN. Every historical score is permanently part of the public record on Physician Compare, and the payment adjustment follows the clinician regardless of employer changes.
06Can an orthopedic practice report MIPS as a group rather than individually?
Yes. Groups can elect group reporting, in which performance is aggregated at the TIN level and a single composite score applies to all clinicians under that TIN. Group reporting can improve scores by pooling high-volume encounter data, but it also means that lower-performing clinicians benefit or suffer collectively. Individual clinicians' historical scores are still publicly reported at the NPI level.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

  1. 01
    qpp.cms.gov
    https://qpp.cms.gov/get-started/what-is-mips/about-mips
  2. 02
    cms.gov
    https://www.cms.gov/files/document/mips-orthopedic-specialty-guideremediated2017-10-18pdf
  3. 03
    mdinteractive.com
    https://mdinteractive.com/MIPS
  4. 04
    mdinteractive.com
    https://mdinteractive.com/2024_MIPS_Orthopedic_Surgery
  5. 05
    aaos.org
    https://www.aaos.org/quality/coding-and-reimbursement/
  6. 06
    edhub.ama-assn.org
    https://edhub.ama-assn.org/steps-forward/module/2844245

Mira AI Scribe

Mira's documentation layer participates in MIPS performance by ensuring encounter-level documentation satisfies the denominator and numerator requirements for the Quality measures an orthopedic practice has selected. Specifically, Mira flags when a visit type matches a MIPS Quality measure denominator (e.g., a follow-up for total knee arthroplasty that qualifies for functional status outcome reporting) and prompts the clinician to complete the required data element before the encounter is closed. For Promoting Interoperability, Mira tracks whether CPOE, clinical decision support, and electronic prescribing actions are being recorded in a manner attributable to the certified EHR technology, reducing the risk of a failed PI attestation. Mira also surfaces mid-year performance summaries so the practice can identify measures where the numerator rate is trailing below the benchmark needed to earn maximum decile points—enabling corrective action before the reporting window closes rather than after. Where a clinician qualifies for a MIPS hardship or extreme-circumstance exception, Mira surfaces the relevant CMS exception application pathway and deadline (December 31 of the performance year) directly in the workflow. Mira does not determine the final MIPS composite score—that calculation is performed by CMS—but its documentation scaffolding directly reduces the two most common sources of MIPS score loss in orthopedic practices: incomplete Quality measure numerator capture and PI measure attestation gaps.

See Mira's approach

Related terms

MACRA Reimbursement

MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is the bipartisan federal law that repealed the Sustainable Growth Rate formula and replaced it with the Quality Payment Program, which ties Medicare physician reimbursement to value-based performance through MIPS or alternative payment models.

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