Glossary · Reimbursement

Quality Payment Program (QPP)

The Quality Payment Program (QPP) is a CMS value-based reimbursement framework, established under MACRA in 2015 and launched in 2017, that ties Medicare Part B payment adjustments to clinician performance through two tracks: MIPS and Advanced APMs.

Verified May 8, 2026 · 6 sources ↓

Drawn from CMSAAOSAanem

Definition

Source · Editorial summary grounded in 6 cited references ↓

The Quality Payment Program replaced the flawed Sustainable Growth Rate (SGR) formula, which had threatened repeated steep cuts to Medicare physician payments. Under MACRA, CMS built QPP around two participation tracks. The Merit-based Incentive Payment System (MIPS) consolidates three legacy programs—PQRS, the Value-based Modifier, and EHR Meaningful Use—into a single scored framework with four performance categories: Quality, Cost, Promoting Interoperability, and Improvement Activities. Scores determine a positive, neutral, or negative payment adjustment applied two years after the performance year. Advanced Alternative Payment Models (Advanced APMs) offer a separate pathway; clinicians who meet participation thresholds may earn a Medicare incentive payment instead of navigating MIPS scoring.

For orthopedic surgeons, MIPS is the dominant pathway. A surgeon must meet all three low-volume thresholds—more than $90,000 in Part B allowed charges, more than 200 Medicare beneficiaries, and more than 200 covered professional services—to be required to participate. Surgeons below any single threshold are excluded. Participation can be reported at the individual, group, virtual group, or APM Entity level, giving practices flexibility to pool data and reduce administrative burden.

CMS designed QPP with ten program objectives, ranging from improving beneficiary outcomes and lowering program costs to expanding APM participation and supporting small, rural, and underserved practices. Beginning in the 2025 performance year, MIPS Value Pathways (MVPs) provide specialty-relevant subsets of measures, making reporting more clinically meaningful for surgical specialties including orthopedics.

Why it matters

Payment adjustments under MIPS are permanent changes to a surgeon's Medicare fee schedule rate for an entire calendar year, not one-time bonuses. A poor performance year—or a failure to submit any data—can trigger a negative adjustment of up to several percentage points on every Medicare Part B claim for that year, compounding across high-volume orthopedic practices. Conversely, high performers can receive upward adjustments and may qualify for exceptional performance bonuses. Misunderstanding eligibility thresholds, reporting deadlines, or category weights can silently expose a practice to penalties that are only discovered when remittance advice arrives two years later—with no retroactive correction available.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

Assuming QPP participation is optional: surgeons above all three low-volume thresholds are automatically subject to MIPS payment adjustments even if they never intentionally enroll.
Treating QPP and MIPS as synonyms: QPP is the overarching program; MIPS and Advanced APMs are the two distinct tracks within it.
Reporting quality measures for the full year and ignoring the Cost category: Cost is CMS-calculated from claims data without any submission required, but it still carries a significant weight in the final MIPS score.
Missing the CAHPS for MIPS Survey registration deadline: groups intending to use the patient experience survey as a quality measure must register separately with CMS before the annual cutoff—missing it forfeits access to those measures for that performance year.
Overlooking eligibility re-checks each program year: the low-volume thresholds are re-evaluated annually, so a practice that was excluded one year may be required to participate the next.
Conflating MIPS Value Pathways (MVPs) with traditional MIPS: starting in 2025, MVPs use a distinct subset of measures; selecting the wrong reporting pathway can result in incomplete submissions and a lower score.

Frequently asked questions

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

01How do I know if I am required to participate in QPP this year?

Enter your NPI into the QPP Participation Look Up Tool at qpp.cms.gov. You are subject to MIPS if you exceed all three low-volume thresholds: more than $90,000 in Part B allowed charges, more than 200 Medicare beneficiaries, and more than 200 covered professional services in the determination period.

02What happens if an orthopedic surgeon does not submit any QPP data?

Failing to submit results in the minimum MIPS score, which triggers the maximum negative payment adjustment applied to all Medicare Part B claims during the applicable payment year—currently up to a several-percentage-point reduction on every claim for that entire year.

03What is the difference between MIPS and an Advanced APM?

MIPS scores performance across four categories and translates that score into a Medicare payment adjustment. An Advanced APM is a risk-bearing payment model (such as certain bundled payment or ACO arrangements); clinicians who qualify as Qualified APM Participants bypass MIPS scoring and instead earn a separate Medicare incentive payment.

04Are MIPS payment adjustments applied immediately in the same year as performance?

No. There is a two-year lag. Performance data collected in 2025 determines payment adjustments applied in 2027. This delay means errors or missed submissions cannot be corrected once the performance year closes.

05What are MIPS Value Pathways and should orthopedic practices use them?

MVPs are CMS-defined subsets of measures and improvement activities organized around a clinical specialty or condition. Starting in the 2025 performance year they become a primary reporting option. Orthopedic-relevant MVPs allow surgeons to report a smaller, more clinically coherent set of measures rather than selecting individually from the full MIPS measure universe, potentially reducing administrative burden while improving score relevance.

06Can a group practice report QPP data collectively rather than individually?

Yes. Orthopedic practices can elect group reporting, which aggregates performance data across all NPIs billing under a single TIN. Group reporting can be advantageous for smaller individual volumes but requires that the entire group's data meet the reporting thresholds together.

Sources & references

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

Mira AI Scribe

Mira's documentation layer flags QPP-relevant context at the point of care. When a note is generated for a Medicare Part B patient, Mira checks whether the rendering provider's NPI is above the low-volume threshold (based on the most recent eligibility data loaded from qpp.cms.gov) and, if so, surfaces applicable MIPS quality measure numerator and denominator criteria relevant to the documented diagnosis and procedure. For orthopedic encounters, this includes measures tied to functional outcome tools (e.g., PRO collection prompts), appropriate imaging utilization, and perioperative care processes. Mira tags documentation gaps that would prevent a measure from being counted as 'met,' allowing the clinician or coder to address them before the encounter is closed. For practices reporting under an MVP, Mira filters displayed measures to the assigned pathway so irrelevant measures do not clutter the workflow. Mira does not auto-submit data to the QPP portal; it prepares structured, submission-ready data for the practice's registry or EHR to transmit. The scribe also logs whether the visit was conducted via telehealth, which affects Promoting Interoperability measure eligibility. All QPP-related flags are surfaced as advisory—final reporting decisions remain with the clinician and billing staff.

See Mira's approach

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.

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.