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2024 Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) Toolkit

Background

The Medicare Access and CHIP Reauthorization Act of 2015— also known as MACRA—was signed into law on April 16, 2015. This law, which created the Quality Payment Program (QPP), changed the way physicians are paid for providing services under Medicare. It continued the move away from fee-for-service payment, toward value-based payment approaches that endeavor to pay clinicians based on the quality, value, and outcomes of the care they provide.

Clinicians can participate in the QPP via two separate tracks: the Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).

MIPS vs APMS

Source: U.S. Centers for Medicare & Medicaid Services

With MIPS, clinicians earn payment adjustments (either bonuses or penalties) for Part B covered professional services, based on four performance categories:

Quality
Cost
Improvement activities
Promoting interoperability

For 2024, clinicians who are eligible to participate in MIPS can report via one of three options:

Traditional MIPS
MIPS Value Pathways (MVPs)
APM Performance Pathway (APP) (only available to clinicians who participate in a MIPS APM)

MVPs are the newest reporting option, offering clinicians a subset of measures and activities relevant to a specialty or medical condition. The Centers for Medicare and Medicaid Services (CMS) notes that MVPs offer more meaningful groupings of measures and activities, to provide a more connected assessment of the quality of care. MVPs include the same four performance categories as Traditional MIPS (i.e., Quality, Cost, Improvement Activities, and Promoting Interoperability). However, the quality measures, cost measures, and improvement activities that are included in a particular MVP have been selected based on their alignment with the focus of the MVP (i.e., a specific condition or specialty). As such, most MVPs are limited to 10-20 quality measures, 1-3 cost measures, and 10-20 improvement activities. The “foundational layer” of all MVPs includes the Promoting Interoperability performance category, where the measures and attestations are identical to those in Traditional MIPS, as well as two population health measures that CMS calculates based on administrative claims. For 2024, participants will select which of the two population health measures they want CMS to calculate. The measures and attestations in the foundational layer are identical across all MVPs.

New MIPS Value Pathways Framework

Source: https://qpp.cms.gov/mips/mvps/learn-about-mvp-reporting-option; https://www.youtube.com/watch?v=1pfY_T_Y1pY&t=82s

Voluntary MVP and subgroup reporting started in 2023. Beginning in 2026, any multispecialty groups intending to report MVPs will be required to report as subgroups or individuals. CMS plans to sunset Traditional MIPS in the future, at which point MVPs will become mandatory, unless the clinician is eligible to report the APP.

Transition from Traditional MIPS to MVPs

Source: CMS; 2024 MIPS MVPs Implementation Guide

There are 16 finalized MVPs available for the 2024 performance year. The AUA Quality (AQUA) Registry supports two MVPs for the 2024 performance year: Advancing Cancer Care and Focusing on Women’s Health.

The 2024 MIPS performance year spans from January 1-December 31, and data collected for this timeframe must be reported to CMS by March 31, 2025. Payment adjustments based on 2024 performance will be made in 2026.

This toolkit focuses on 2024 participation rules, performance categories, and scoring approaches for MVP reporting. NOTE that MIPS participants may report via Traditional MIPS and MVPs. If participants report via both options, CMS will calculate final scores for each and use one that is highest.

Participation in MIPS

As noted in the previous section, MVPs are one option for meeting MIPS reporting requirements. To report via MVP, the participant must be MIPS-eligible. CMS provides the QPP Participation Status Lookup Tool, which allows providers to view their MIPS eligibility status, including whether or not he/she is required to report. Only certain types of clinicians can participate (including physicians, physician assistants, and nurse practitioners, among others).

A clinician is required to participate in MIPS (i.e., is MIPS-eligible) if he/she is an eligible clinician type and meets all of the following:

Has enrolled as a Medicare provider before January 1, 2024
Is NOT a Qualifying APM Participant
Meets all of the following low-volume threshold criteria:
- Sees more than 200 Medicare Part B patients
- Performs 200 or more covered professional services to Part B patients
- Has $90,000 or more in Medicare Part B covered professional services

Voluntary reporters, opt-in eligible clinicians, and virtual groups cannot report an MVP for the 2024 performance year.

Options for Participation

Participants must register in advance to report an MVP. In 2024, MVP registration opens April 1, 2024 and closes on December 2, 2024. To report Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey as part of an MVP, you must complete MVP registration by July 1, 2024 and must separately register to participate in the CAHPS for MIPS Survey. At the time of registration, participants will need to:

Identify the MVP they plan to report
Any administrative claims they plan to count toward the 4 required quality measures (if applicable). If a participant plans to be evaluated on an administrative claims measure as 1 of their 4 required measures, they will need to indicate this in their MVP registration.
The population health measure they would like to be evaluated on
Whether the participant plans to count the CAHPS for MIPS Survey measure towards the 4 required quality measures (if applicable).
The participation option the participant plans to use (group, subgroup, individual, or APM entity).

To learn more about MVP registration, visit the QPP website.

Providers may be eligible to participate in MIPS via MVPs as an individual clinician, as part of a group, as part of a subgroup (subset of clinicians from the same group, identified by Taxpayer Identification Number (TIN), or as an APM entity. Those participating as an individual are scored independently on the data they submit to CMS. Those participating as a group submit data on measures and activities based on the aggregated performance of clinicians who are billing under a TIN. More specifically, CMS defines a group as a single TIN with 2 or more clinicians (as identified by their National Provider Identifier (NPI)), who have reassigned their Medicare billing rights to that TIN. At least one clinician within the group must be MIPS-eligible. The TIN’s payment adjustment will be based on the group’s final score from the MIPS performance categories. If someone wishes to submit data for both individual and group reporting, CMS will analyze both sets of data and use the option with the higher score.

Subgroups must include at least two clinicians from the same TIN, at least one of whom must be individually eligible for MIPs. At present, CMS has not created additional restrictions on how subgroups are formed. Subgroup reporting may be of interest to those in large practices or in multi-specialty groups. As noted earlier, subgroup reporting is voluntary for 2024. However, CMS plans to require subgroup reporting for those in multispecialty groups beginning in 2026.

An APM Entity includes all eligible clinicians participating with an APM Entity at certain times during the year. CMS defines an APM Entity as one that participates in an Alternative Payment Model or other payer arrangement through a direct agreement with CMS or other payer, or through Federal or State law or regulation. Note that the performance categories are weighted differently for this option because APM Entities are not scored on the cost category. Additional information is provided on the CMS QPP website.

Available MVPs

The following MVPs are available for reporting in 2024.

The MVPs denoted with an “*” in the list above include several measures that are applicable for some urologists and are thus supported by the AQUA Registry.

Performance Category Weights, Scoring, and Payment Impact

As noted earlier, the basic scoring categories for MIPS and MVPs are similar, although the performance categories are structured somewhat differently.

Scoring MIPS and MVPs

Source: CMS; MVPs Town Hall: January 7, 2021

For 2024, the weights of the four performance categories for individuals, groups, and subgroups are as follows:

Quality (30%)
- Participants are required to report on at least 4 measures from the MVP. At least one measure must be an outcome measure. If an outcome measure is not available, a high priority measure must be reported.
- One Population Health Measure (included in the “Foundational Layer”) is calculated via administrative claims and is included in the final “Quality” scoring.
Cost (30%)
Improvement Activities (15%)
Promoting Interoperability (PI) (25%)
- Included in the “Foundational Layer”

Traditional MIPS and MVP Performance Category Weights in 2024

Source: CMS; 2024 MIPS Overview Quick Start Guide

Clinicians reporting an MVP will receive feedback comparing their performance in each category to other clinicians reporting the same MVP. However, clinicians reporting an MVP will not be scored solely in comparison to the other clinicians reporting that MVP.

Each performance category is scored separately, with the four component scores added together for a total score. Participants must achieve at least 75 points in order to avoid a negative payment adjustment (penalty). The performance threshold remained 75 points from performance year 2023 to 2024. Those who do not participate will incur a 9 percent penalty on their 2026 Part B Medicare payments, and those falling between zero and <75 points will face a penalty to some degree. Those scoring more than 75 points will receive a positive payment adjustment (bonus) of some degree. MIPS is a budget neutral program, meaning the penalties must pay for the bonuses; thus, the amount of the bonuses will be determined once CMS determines the amount of funds available. Note that performance categories may be re-weighted from the above values in certain circumstances (e.g., for small practices, for approved extreme and uncontrollable circumstances, etc.).

2020 Quality Payment Program Proposed Rule Overview

Source: CMS; 2020 Quality Payment Program Proposed Rule Overview

The image below outlines the basic information for each reporting category in MVPs.

Basic information for each reporting category in MVPs

Source: CMS; 2024 MIPS Overview Quick Start Guide

Performance Category: Quality (30%)

The Quality performance category focuses on measures that assess health care processes, outcomes, and patient experiences of care. There are two components to this performance category:

Participants must report data for at least 4 quality measures from the MVP (one of which must be an outcome measure, or a high-priority measure, in the absence of an applicable outcome measure). Participants can opt to report on more than four measures; in that case, CMS will use the four measures with the highest scores.
Participants must select one of the two Population Health Measures at the time of MVP registration. The Population Health Measure (included in the “Foundational Layer”) is calculated via administrative claims.

Make sure to select measures that are appropriate to your patient population. Measures that do not meet case minimum or data completeness criteria will earn zero points. In 2024, the weight for the Quality performance category is 30 percent for individuals, groups, and subgroups (that is, this category accounts for 30% of the total MIPS score).

Data Collection Types

There are several different ways that measures can be collected and reported for MIPS. In 2024, participants may use a combination of any of these options to complete their MIPS reporting. The possible reporting options for each specific measure are listed in the measure specifications.

A Qualified Clinical Data Registry (QCDR) is a CMS-approved entity (such as a registry, certification board, specialty society, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. Individuals and groups may report via a QCDR. The AUA offers its own QCDR, the AQUA Registry. For more information, contact 855-898-AQUA (2782) or AQUA@AUAnet.org. Please note that the AQUA Registry may not support a QCDR measure included in a supported MVP.

Medicare Part B Claims reporting may be used only by those who are members of a practice with 15 or fewer providers. This reporting option involves submitting extra CPT Category II codes (also known as Quality Data Codes or G codes) along with regular billing CPT codes and diagnosis codes on electronic or paper claims submitted to Medicare. Medicare then forwards these claims files to the processor. To meet data completeness requirements, practices will need to start reporting the Medicare Part B claims measures in their selected MVP in January 2024, prior to the MVP registration period.

MIPS Clinical Quality Measures (CQM) reporting may be used by both individuals and groups. It is accomplished by contracting with a CMS-approved data processing service that can compile patient data and generate reports on a provider’s or practice's behalf directly to the MIPS processor. Depending on the vendor, data can be transferred to the registry in a number of ways.

Electronic Clinical Quality Measures (eCQM) reporting involves either submitting one’s data directly to CMS or to a vendor who will then submit it to CMS on the provider or practice’s behalf. Check with your electronic health record (EHR) vendor to find out what option(s) is available to you.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey is an optional measure for participating groups, subgroups, and APM entities reporting through the MIPS program. The CAHPS for MIPS Survey measure is a patient experience measure; note that there are beneficiary sampling requirements for this measure. The survey must be administered by a CMS-approved vendor. Participants must register between April 3, 2024, and June 30, 2024, to report on the CAHPS for MIPS Survey measure.

Quality Measures in AQUA-supported MVPs

For 2024, the AQUA Registry supports two MVPs (the Advancing Cancer Care MVP and the Focusing on Women’s Health MVP). Note not all quality measures from the MVPs are supported in the AQUA Registry.

Advancing Cancer Care

The Advancing Cancer Care MVP focuses on the clinical theme of providing fundamental treatment and management of cancer care. The measures assess three critical areas: the patient experience of care, end of life care, and appropriate diagnostics along with possible treatment options for different cancer diagnoses. Measure numbers in bold font are supported in the AQUA Registry.

#047: Advance Care Plan [MIPS CQM, Claims]^!†
#134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan [eCQM, MIPS CQM, Claims]^†
#143: Oncology: Medical and Radiation - Pain Intensity Quantified [eCQM, MIPS CQM]^!
#144: Oncology: Medical and Radiation - Plan of Care for Pain [MIPS CQM]^!
#321: CAHPS for MIPS Clinician/Group Survey^!
#450: Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer [MIPS CQM]^!
#451: RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy [MIPS CQM]
#452: Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies [MIPS CQM]^!
#453: Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) [MIPS CQM]^!
#457: Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better) [MIPS CQM]^!
#462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy [eCQM]
#487: Screening for Social Drivers of Health [MIPS CQM]^!
#490: Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors [MIPS CQM]
#503: Gains in Patient Activation Measure (PAM) Scores at 12 Months [MIPS CQM]^!
PIMSH13: Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy [QCDR]^!
PIMSH2: Oncology: Utilization of GCSF in Metastatic Colorectal Cancer [QCDR]^!

^!High priority measure; ^†If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don't need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.

Focusing on Women’s Health

Focusing on Women’s Health MVP focuses on the clinical theme of providing treatment and management of women’s health. Measure numbers in bold font are supported in the AQUA Registry.

#048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older [MIPS CQM]
#112: Breast Cancer Screening [eCQM, MIPS CQM, Claims]
#134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan [eCQM, MIPS CQM, Claims]
#226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention [eCQM, MIPS CQM, Claims]
#309: Cervical Cancer Screening [eCQM]
#310: Chlamydia Screening for Women [eCQM]
#335: Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) [MIPS CQM]^!
#336: Maternity Care: Postpartum Follow-up and Care Coordination [MIPS CQM]^!
#400: One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation [MIPS CQM]
#422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury [MIPS CQM, Claims]^!
#431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling [MIPS CQM]
#432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair [MIPS CQM]^!
#448: Appropriate Workup Prior to Endometrial Ablation [MIPS CQM]^!
#472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture [eCQM]^!
#475: HIV Screening [eCQM]
#487: Screening for Social Drivers of Health [MIPS CQM]^!
#493: Adult Immunization Status [MIPS CQM]
#496: Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument [MIPS CQM]
UREQA8: Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved [QCDR]^!

^!High priority measure

Population Health Measures

Participants must select one of the two population health measures (below) at the time of MVP registration. Participants do not have to submit any data for this measure, as CMS will calculate population health measures using administrative claims data. The population health measure does not count as one of the required 4 quality measures, but it will be included in the final score for the quality performance category. Participants can earn between 1 and 10 points for their selected population health measure based on comparison to a performance period benchmark.

If the MVP participant doesn’t meet case minimum for either population health measure, the measure will be excluded from scoring.

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups (available for groups only – subgroups will be evaluated at the affiliated group level):
- The Hospital-wide, 30-Day, All-cause Unplanned Readmission (HWR) rate for the Merit-based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for Medicare Fee-for-Service (FFS) beneficiaries aged 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s readmission rate.
Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
- The measure is an annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians or clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN), or to Accountable Care Organizations (ACOs), as identified by an aggregate of TINs that participate in these ACOs. The measure is calculated for MIPS TINs/ACOs with at least 16 clinicians per group and a case minimum of at least 18 patients with MCCs. Lower measure scores indicate better performance.

Scoring the Quality Category

MVP participants earn points for the Quality category based on how their results compare to that of other participants. As detailed below, measure results are compared to benchmarks based on historical data to determine the number of achievable points for submitted quality measures and the population health measure. Next, bonus points are awarded, as applicable, and a percentage score is computed. Then, the final score for the Quality performance category is calculated by weighting the Quality percentage score by the Quality weight (for 2024, this is 30 percent for individuals, groups, and subgroups).

Quality Benchmarks

For each measure, for each reporting mechanism, a series of historical benchmarks has been established (for 2024, these benchmarks have been calculated based on data submitted for 2022). CMS created a matrix where each measure’s results have been divided into deciles, ranging from 1 to 10. Measures typically can earn between 1 and 10 achievement points if they can be scored against a benchmark. Participants can use this matrix to determine into which decile his/her performance falls, then use this information to determine the score for that particular measure.

If a measure is considered “topped out” by CMS, this means most participants who have reported the measure have scored very well on it. CMS has begun phasing out many of the topped-out measures and is trying to discourage participants from using remaining topped out measures by awarding lower point values. For some topped-out measures, CMS does not award the full 10 points, even if measure results are perfect.

Each measure, and its reporting mechanism, has its own unique benchmarks. For example, a measure collected through Medicare Part B claims may have a different benchmark than if collected through a CQM or eCQM. Thus, participants will want to assess the potential benchmarks when they contemplate which measures to report. Measures, whether reporting via MVPs, MIPS, or APPs will be scored against the same benchmark identified in the 2024 Quality Benchmarks file (or calculated based on performance period data) for their selected collection type.

If a measure does not have a historical benchmark, CMS will attempt to calculate one using 2024 data. If no historical benchmark exists and one cannot be calculated using 2024 data, for most participants, CMS will not award any points for that measure. However, small practices will earn 3 points for reporting on measures without a benchmark.

For a new measure in its first performance year, a minimum of 7 points will be awarded for those who successfully report on such a measure. During its second performance year, the measure will have a 5-point floor.

The benchmark values for measures are available in a comma-delimited file located on the CMS QPP Website. Note that the benchmark values are subject to change during the year, so clinicians should check the QPP website periodically to see if a revised version of the benchmark file has been released.

Quality Bonus Points and Quality Improvement Scoring

Bonus Points: Bonus points are available for small practices only. For those in a practice with 15 or fewer clinicians who submit data for at least one quality measure, six bonus points will be awarded.

Quality Improvement Scoring: MVP participants may be able to earn as many as 10 additional percentage points if their score for the Quality category improved compared to their score in the previous year. If an MVP participant reported via Traditional MIPS the prior performance year, CMS will use that achievement score to calculate the improvement score for the current performance year. The bonus is awarded using the formula: 10 x (increase in achievement percent score from prior performance year / prior performance year achievement percent score).

Quality Improvement Score Example:

Quality Improvement Score Example

Source: CMS; 2024 MIPS MVPs Implementation Guide

Calculating the Final Score for the Quality Performance Category

To calculate a provider’s Quality category score, one must use the benchmark information for each measure to determine the number of achievable points for that measure. Those points are added together, along with any bonus points that have been earned. That total is divided by total number of achievable measure points (in most cases, this is 50 points – 40 points from the quality measures and 10 points from the population health measure). If an improvement percent score has been earned, it is then added to this value to determine the final score. The score is displayed as a percentage, but a maximum final score cannot exceed 100 percent.

If a participant scores perfectly on all four measures and the one population health measure and achieved 10 points for each, that participant would receive a Quality percentage score of 100 percent (50/50 * 100%). However, most participants will not have perfect scores on each submitted measure. For example, a participant may have the following scores for four measures: 8.5, 7.9, 7.2, and 8.2, for a total of 31.8 points) and 7.1 points for the population health measure. The total number of points would be 38.9, which is then then divided by 50 (this equals 77.8 percent). But this participant is also awarded an improvement percent score of 4.21 percent. Then, that participant’s percentage score for the Quality category is 82 percent. Finally, the formula for determining the total points for the Quality category is: (quality performance category percent score) x (quality category weight) x 100.

Using the example above, the Quality performance category score would be: 82 percent x 30 percent x 100 =24.6 points.

Example of the Quality Performance Category Scoring

Source: CMS; 2024 MIPS MVPs Implementation Guide

Note that the Quality category weight might change for some participants. For example, small practices are not required to report on the Promoting Interoperability category. If small practices do not submit data for this category, the Quality category weight becomes 40 percent in 2024. For MVPs, the Quality performance category will not be reweighted if CMS cannot calculate a score for the MIPS eligible clinician because there isn’t at least one quality measure applicable and available to the clinician.

Performance Category: Cost (30%)

The measures included in the Cost performance category assess the overall cost of care provided to Medicare patients, with a focus on the primary care they received; the cost of services provided to Medicare patients related to a hospital stay; and costs for items and services provided during specific episodes of care. Participants do not select cost measures during MVP registration. CMS will calculate the performance on all the cost measures included in the MVP based on available Medicare claims data. Participants do not need to submit data for the Cost performance category. Participants will only be scored on the MVP cost measures in the MVP for which they meet or exceed the established case minimum. In 2024, the weight for the Cost performance category remains 30 percent for individuals, groups, and subgroups (that is, this category accounts for 30% of the total MIPS score).

Cost Measures in AQUA-supported MVPs

Advancing Cancer Care

TPCC_1: Total Per Capita Cost (TPCC)
- The TPCC measures the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is a payment-standardized, risk-adjusted, and specialty-adjusted measure.

Focusing on Women’s Health

MSPB_1: Medicare Spending Per Beneficiary (MSPB) Clinician
- The MSPB Clinician measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (hereafter referred to as the “episode”), which comprises the period immediately prior to, during, and following the patient’s hospital stay. An episode includes Medicare Part A and Part B claims with a start date between 3 days prior to a hospital admission (also known as the “index admission” for the episode) through 30 days after hospital discharge, excluding a defined list of services that are unlikely to be influenced by the clinician’s care decisions and are, thus, considered unrelated to the index admission.
TPCC_1: Total Per Capita Cost (TPCC)
- The TPCC measures the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is a payment-standardized, risk-adjusted, and specialty-adjusted measure.

Calculating the Final Score for the Cost Performance Category

For the Cost performance category, CMS will compare participants’ performance to that of other MIPS-eligible clinicians and groups during the performance period. More specifically, to calculate the score for each measure, CMS will determine the ratio of standardized observed episode costs to the expected costs and multiply that value by the average episode cost (benchmark). There is a single benchmark for scoring each cost measure, whether it’s being scored as part of an MVP or traditional MIPS.

For each scored measure, CMS will then assign 1-10 achievement points, based on the decile in which the score falls. The Cost performance category percent score is calculated as the total number of achievement points earned divided by the number of possible achievement points (i.e., the total number of scored measures times 10). In addition, there is a maximum cost improvement score of 1 percentage point available for the Cost performance category.

Another example of MVPs

Source: CMS; 2024 MIPS MVPs Implementation Guide

As an example, if a participant is scored on two cost measures (6.8 and 6.1 points) and 0.21% improvement score the Cost performance category percent score would be ((6.8+6.1)/20)*100=64.5% +0.21%= 64.71%.

The formula for determining the total points for the Cost category is: (cost performance category percent score) x (cost category weight) x 100.

Using the example above, the Cost score would be: 64.71 percent x 30 percent x 100 = 19.41 points (out of 30 points).

Performance Category: Promoting Interoperability (25%)

The goal of the Promoting Interoperability (PI) performance category is to foster the electronic exchange of health information using certified electronic health record technology (CEHRT). Use of technology to exchange and make use of information (i.e., interoperability) reduces burden associated with communicating patient information and, by extension, improves patient access to their health information, information exchange between clinicians and pharmacies, and the systematic collection, analysis, and interpretation of healthcare data. In 2024, the weight for the PI performance category is 25 percent for individuals, groups, and subgroups (that is, this category accounts for 25% of the total MIPS score).

The PI performance category is included in the “Foundational Layer” of the MVP, meaning that the PI measures will be the same for every MVP.

The PI category focuses on 4 objectives:

e-Prescribing
Health Information Exchange
Provider-to-Patient Exchange
Public Health and Clinical Data Exchange

Participants must have CEHRT functionality that meets the Office of the National Coordinator for Health IT (ONC’s) certification criteria in 45 CFR 170.315 in place by the first day of their MIPS PI performance period and have their EHR certified by ONC to the certification criteria in 45 CFR 170.315 by the last day of their performance period. Participants should check with their EHR vendor if unsure of their CEHRT version.

Some participants may be automatically exempted from this performance category (based on special status (such as a hospital-based clinician, small practice size, or clinician type), and others may qualify for a hardship exception (have decertified EHR technology, have insufficient internet connectivity, lack control over CEHRT availability, or face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress, or vendor issues). This exception results in the re-weighting of the PI category to zero. If any data are submitted for the PI category, the reweighting will be canceled, and the data will be scored. Those who are not automatically exempted must apply for the exception. Even if a participant received an exception previously, they must apply again in 2024.

Participants can report as an individual, group, subgroup, or APM Entity, either directly or through a third party such as the AQUA registry.

PI Measures

For the PI performance category, participants must report on either 6 or 7 required measures. Data for these measures must be collected during the same continuous 180-day period (or more) during the calendar year.

In addition to the PI measures, participants must provide their EHR’s CMS Identification code from the Certified Health IT Product list and complete the required attestations.

Information about the PI measures is shown below.

Table showing PI measures

Source: CMS; 2024 MIPS MVPs Implementation Guide

The specifications for the measures are posted on the CMS QPP Website.

Note that the work required for all PIs must begin no later than July 5, 2024 (in order to have a full 180-day performance window). As with the Improvement Activities performance category, documentation supporting PI reporting is not required at the time of attestation. However, documentation should be compiled and would be required in the event of a CMS audit. Participants must keep this documentation for six years after attestation. Requirements for this documentation can be located on the CMS QPP Resource Library webpage.

Participants cannot combine performance data submitted between different reporting options (e.g., traditional MIPS and MVPs) into a single final score or submit performance data for one performance category and count it for both reporting options. For example, PI data cannot be reported for traditional MIPS and count towards the PI category for an MVP. More specifically, although the PI data may be the same, there must be two separate submissions: one for traditional MIPS and one for MVP reporting (with the appropriate MVP identifier, and subgroup identifier if applicable). In addition, each MVP submission must include the related MVP ID, signaling the participant’s intent to report the PI data for their selected MVP. Any data submitted without the necessary MVP ID will be attributed to traditional MIPS instead of the MVP.

If the participant is reporting an MVP as a subgroup, they will submit their affiliated group’s data for the PI performance category.

Calculating the Final Score for the Promoting Interoperability Performance Category

Participants can earn 100 measure points based on results of required measures, with the option to earn 5 bonus points by submitting a “yes” response for one or more of the optional Public Health and Clinical Data Exchange measures. However, total points will be capped at 100. Claiming an allowed measure exclusion causes the measure’s points to be shifted to a different measure for most measures.

A score of zero points will be earned for the PI performance category unless:

A participant reports either a numerator of at least ‘1’ or a ‘yes’ for required measures, assuming an exclusion is not claimed
Data are collected in CEHRT with functionality that meets ONC requirements for at least 180 continuous days in 2024
A “yes” is submitted to the Actions to Limit or Restrict Interoperability of CEHRT Attestation (formerly named Prevention of Information Blocking)
A “yes” is submitted to the SAFER Guides attestation measure
A “yes” or “no” is submitted to the ONC Direct Review Attestation
A “yes” is submitted to show that a participant has completed the Security Risk Analysis measure in 2024
The level of active engagement for the Public Health and Clinical Data Exchange measures being reported is submitted
The EHR's CMS identification code from the Certified Health IT product List (CHPL) is reported.

Points for each measure are earned depending on the type of measure. Measures with a numerator and denominator receive points based on their results, which are multiplied by the maximum number of points available for the measure. As an example, if a participant has a 75% performance for the Provide Patients Electronic Access to Their Health Information measure (which is worth a maximum of 25 points), he/she would earn 19 points (0.75*25) towards the PI performance category. Attestation measures where the participant responds “yes” receive the maximum number of points available for the measure. If the participant responds “no” to an attestation measure, they will earn zero points for the measure.

An example of e-Prescribing measure

Source: CMS; 2024 MIPS MVPs Implementation Guide

To calculate the final percent score for the PI performance category, sum the points earned for each measure and divide by 100. Note, however, that the score is capped at 100 percent. The formula to determine the total points for the PI category is: (PI performance category percent score) x (PI category weight) x 100.

As an example, if the final percent score for the PI category is 91 percent, the final Promoting Interoperability score would be: 91 percent x 25 percent x 100 =22.75 points (out of 25 points).

Information on calculations

Source: CMS; 2024 MIPS MVPs Implementation Guide

Performance Category: Improvement Activities (15%)

The Improvement Activities (IA) performance category measures participation in activities that improve clinical practice, care delivery, and outcomes. In 2024, the weight for the IA performance category is 15 percent for individuals, groups, and subgroups (that is, this category accounts for 15 percent of the total MIPS score). MVP participants will earn twice the number of points that they would earn reporting the same activity through traditional MIPS.

Scoring for Improvement Activities

Source: CMS; 2024 MIPS MVPs Implementation Guide

To receive full credit for the improvement activities performance category (40 points), participants must submit 1 high-weighted activity or 2 medium-weighted activities included in the MVP.

IAs must be implemented for at least one continuous 90-day performance period (during 2024) unless otherwise stated in the activity description. IAs can be reported by individuals or through group reporting. If a practice is using group reporting, at least 50 percent of the members of the practice must implement the same IA in order to earn credit, although they do not have to implement it at the same time.

Each IA typically is given a medium weight (20 points) or a high weight (40 points). The maximum number of points available for this performance category is 40. Those working in a recognized or certified patient-centered medical home or comparable specialty practice can receive the full 40 points for this category (IA_PCMH). All IAs must begin no later than October 3, 2024 (to have a full 90-day performance window).

Participants will attest to their improvement activities (note that this can be done directly or through a third party, such as the AQUA registry). Documentation supporting improvement activities is not required at the time of attestation. However, documentation should be compiled and would be required in the event of a CMS audit. Participants must keep this documentation for six years after attestation. CMS has published requirements for this documentation. The AUA recommends that participants document as much information as possible about the activities you complete. For example, if administering a patient satisfaction survey for 90 days, note in the patient charts who received one and when. Or, if attending an Institute for Healthcare Improvement event, save proof of registration and any materials (slides, handouts, etc.) that may have been distributed for the event.

An MVP participant that also participates in an APM will automatically receive an improvement activities performance category score of 50%. These MVP participants would only need to report one medium-weighted improvement activity to receive full points in this performance category.

Getting Started

IAs are organized into eight categories, as follows:

Achieving Health Equity (AHE)
Behavioral and Mental Health (BMH)
Beneficiary Engagement (BE)
Care Coordination (CC)
Emergency Response and Preparedness (ERP)
Expanded Practice Access (EPA)
Patient Safety and Practice Assessment (PSPA)
Population Management (PM)

When considering IAs:

You should review the full list of activities in the MVP to see which are most applicable to your practice.
Carefully review the CMS documentation requirements to ensure you understand and can meet them.

IAs in AQUA-supported MVPs

Advancing Cancer Care

Activity	Activity Description	Activity Weight
IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care	Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.	Medium
IA_BE_24: Financial Navigation Program	In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.	Medium
IA_BE_4: Engagement of patients through implementation of improvements in patient portal	To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.	Medium
IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings	Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.	High
IA_BMH_12: Promoting Clinician Well-Being	Develop and implement programs to support clinician well-being and resilience—for example, through relationship-building opportunities, leadership development plans, or creation of a team within a practice to address clinician well-being—using one of the following approaches: •Completion of clinician survey on clinician well-being with subsequent implementation of an improvement plan based on the results of the survey. •Completion of training regarding clinician well-being with subsequent implementation of a plan for improvement.	High
IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop	Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.	Medium
IA_CC_13: Practice Improvements to Align with OpenNotes Principles	Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.	Medium
IA_CC_17: Patient Navigator Program	Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.	High
IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record	Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following: •Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care); •Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or •Provision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.	High
IA_EPA_2: Use of telehealth services that expand practice access	Create and implement a standardized process for providing telehealth services to expand access to care.	Medium
IA_ERP_4: Implementation of a Personal Protective Equipment (PPE) Plan	Implement a plan to acquire, store, maintain, and replenish supplies of personal protective equipment (PPE) for all clinicians or other staff who are in physical proximity to patients. In accordance with guidance from the Centers for Disease Control and Prevention (CDC) the PPE plan should address: •Conventional capacity: PPE controls that should be implemented in general infection prevention and control plans in healthcare settings, including training in proper PPE use. •Contingency capacity: actions that may be used temporarily during periods of expected PPE shortages. •Crisis capacity: strategies that may need to be considered during periods of known PPE shortages. The PPE plan should address all of the following types of PPE: •Standard precautions (e.g., hand hygiene, prevention of needle-stick or sharps injuries, safe waste management, cleaning and disinfection of the environment) •Eye protection •Gowns (including coveralls or aprons) •Gloves •Facemasks •Respirators (including N95 respirators)	Medium
IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways	Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity. Create a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following: • Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice; • Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff; • Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives; • Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; or • Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data. Optional activities related to this activity (but do not count towards completion of this IA) include the following: • Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; and • Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.	High
IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation	To be eligible for patient-centered medical home or comparable specialty practice designation, the practice needs to meet one of the following: Have received accreditation from an accreditation organization that is nationally recognized; or Be participating in a Medicaid Medical Home Model or Medical Home Model; or Be a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; or Have received accreditation from other certifying bodies that have certified a large number of medical organizations and meet national guidelines, as determined by the Secretary.	N/A
IA_PM_14: Implementation of methodologies for improvements in longitudinal care management for high risk patients	Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: · Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. · Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; · Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or · Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.	Medium
IA_PM_15: Implementation of episodic care management practice improvements	Provide episodic care management, including management across transitions and referrals that could include one or more of the following: • Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or • Managing care intensively through new diagnoses, injuries and exacerbations of illness.	Medium
IA_PM_16: Implementation of medication management practice improvements	Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or • Conduct periodic, structured medication reviews.	Medium
IA_PM_21: Advance Care Planning	Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.	Medium
IA_PSPA_13: Participation in Joint Commission Evaluation Initiative	Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.	Medium
IA_PSPA_16: Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs	Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools—and standardized treatment protocols to manage workflow on the care team to meet patient needs. Clinicians should focus on utilizing open-source, freely available, interoperable CDS in completing the requirements of this activity.	Medium
IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program	Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria: • The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity; • The activity must have specific, measurable aim(s) for improvement; • The activity must include interventions intended to result in improvement; • The activity must include data collection and analysis of performance data to assess the impact of the interventions; and • The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information. An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).	Medium

Focusing on Women’s Health

Activity	Activity Description	Activity Weight
IA_AHE_1: Enhance Engagement of Medicaid and Other Underserved Populations	To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat data (i.e., data measuring the time between clinician identifying a need for an appointment and the patient having a scheduled appointment) to identify patterns by which care or engagement with Medicaid patients or other groups of underserved patients has not achieved standard practice guidelines; and with this information, create, implement, and monitor an approach for improvement. This approach may include screening for patient barriers to treatment, especially transportation barriers, and providing resources to improve engagement (e.g., state Medicaid non-emergency medical transportation benefit).	High
IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health	Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following: • Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or • Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or • Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. Drivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.	High
IA_AHE_3: Promote Use of Patient-Reported Outcome Tools	Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.	High
IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols	Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following: •Use Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices. •Update and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols. •Update and apply requirements for staff training on food security and nutrition. •Update and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.	Medium
IA_BE_16: Promote Self-management in Usual Care	To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.	Medium
IA_BE_4: Engagement of patients through implementation of improvements in patient portal	To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.	Medium
IA_BMH_11: Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice	Create and implement a plan for trauma-informed care (TIC) that recognizes the potential impact of trauma experiences on patients and takes steps to mitigate the effects of adverse events in order to avoid re-traumatizing or triggering past trauma. Actions in this plan may include, but are not limited to, the following: •Incorporate trauma-informed training into new employee orientation •Offer annual refreshers and/or trainings for all staff •Recommend and supply TIC materials to third party partners, including care management companies and billing services •Identify patients using a screening methodology •Flag charts for patients with one or more adverse events that might have caused trauma •Use ICD-10 diagnosis codes for adverse events when appropriate TIC is a strengths-based healthcare delivery approach that emphasizes physical, psychological, and emotional safety for both trauma survivors and their providers. Core components of a TIC approach are: awareness of the prevalence of trauma; understanding of the impact of past trauma on services utilization and engagement; and a commitment and plan to incorporate that understanding into training, policy, procedure, and practice.	Medium
IA_BMH_14: Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women	Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.	High
IA_CC_9: Implementation of practices/processes for developing regular individual care plans	Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.	Medium
IA_EPA_2: Use of telehealth services that expand practice access	Create and implement a standardized process for providing telehealth services to expand access to care.	Medium
IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways	Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity. Create a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following: • Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice; • Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff; • Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives; • Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; or • Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data. Optional activities related to this activity (but do not count towards completion of this IA) include the following: • Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; and • Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.	High
IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation	To be eligible for patient-centered medical home or comparable specialty practice designation, the practice needs to meet one of the following: Have received accreditation from an accreditation organization that is nationally recognized; or Be participating in a Medicaid Medical Home Model or Medical Home Model; or Be a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; or Have received accreditation from other certifying bodies that have certified a large number of medical organizations and meet national guidelines, as determined by the Secretary.	N/A
IA_PM_23: Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines	Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool within the electronic health record (EHR) system to provide clinicians with ready access to and assisted interpretation of the most up-to-date clinical practice guidelines in CCSM to ensure adequate screening, timely follow-up, and optimal patient care. The CCSM CDS helps ensure that patient populations receive adequate screening and management, according to evidence-based recommendations in the United States Preventive Services Task Force (USPSTF) screening and American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for cervical cancer. The CCSM CDS integrates into the clinical workflow a clinician-facing dashboard to support the clinician’s awareness and adoption of and preventive care for cervical cancer, including screening and any necessary follow-up treatment. The CCSM CDS is fully conformant with the HL7 Fast Healthcare Interoperability Resources (FHIR) standard, so it can be used with any Office of the National Coordinator for Health Information Technology (ONC) certified EHR platform. The CDS Hooks and SMART-on-FHIR interoperability interface standards provide two ways to integrate with the clinical workflow in a way that complements existing displays and information pre-visit, during visit, and for post-visit follow-up. CCSM CDS helps the clinician evaluate the patient’s clinical data against existing guidance and displays patient-specific recommendations.	High
IA_PM_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)	Address inequities in health outcomes by using population health data analysis tools to identify health inequities in the community and practice and assess options for effective and relevant interventions such as Population Health Toolkit or other resources identified by the clinician, practice, or by CMS. Based on this information, create, refine, and implement an action plan to address and close inequities in health outcomes and/or health care access, quality, and safety.	Medium

Disclaimer: The AUA encourages practices to download and review CMS’ improvement activity (IA) data validation requirements. Providers should maintain documentation supporting the compilation of each activity, in the event of a future CMS audit. Additionally, the AUA and AQUA Registry cannot guarantee a positive/negative payment adjustment at any time.

Calculating the Final Score for the Improvement Activities Performance Category

As noted previously, each IA is worth either 20 points or 40 points, and the maximum number of points possible for the IA category is 40. Participants can select whatever combination of activities they desire to reach those 40 points. Again, they must engage in those activities for at least 90 continuous days, unless otherwise stated in the activity description. For individuals, groups, and subgroups, the IA performance category accounts for 15 percent of the overall MIPS score.

As an example, if a participant implemented 2 medium-weight activities, their IA performance category percent score would be (20+20)/40=100 percent. Note, however, that a participant cannot earn more than 100% for this performance category (even if they attest to implementing additional improvement activities).

The formula for determining the total points for the Improvement Activities category is: (IA performance category percent score) x (IA category weight) x 100.

Using the example above, the Improvement Activities score would be: 100 percent x 15 percent x 100 =15 points (out of 15 points).

Calculating the Final Score for the Improvement Activities Performance Category

Source: CMS; 2024 MIPS MVPs Implementation Guide

Calculating the Final MVP Score

An MVP participant will receive a final score based on the same performance category weights used in traditional MIPS, and the same performance category weight redistribution policies apply. The final MIPS score is calculated by adding together the final scores for each of the four performance categories, along with any “complex patient” bonus points earned.

Complex Patient Bonus: CMS recognizes the challenges and costs incurred by clinicians for caring for complex patients. Therefore, CMS will analyze participant data to determine the number of bonus points (if any) for complex patients. The bonus is based upon average Hierarchical Condition Category (HCC) risk scores that incorporate age, sex, and diagnoses from the previous year (to determine medical complexity) and the proportion of patients with dual Medicare-Medicaid eligibility (as a proxy for social risk). Up to 10 bonus points may be awarded, depending on the level of clinical complexity and social risk.

Example MVP scoring:

Example of MVP Scoring

Source: CMS; 2024 MIPS MVPs Implementation Guide

Additional Information

CMS has developed extensive descriptions for, and detailed documentation of, the requirements and operation of the MIPS program and MVPs. These are available on its QPP website. A few of the most helpful resources, available through this site’s Resource Library, include:

2024 MIPS Overview Quick Start Guide

2024 MIPS Eligibility and Participation Quick Start Guide

2024 MVP Implementation Guide

2024 MVP Registration Guide

2024 Quality Benchmarks

2024 MIPS Cost Measure Codes Lists

2024 Improvement Activities Inventory

2024 Promoting Interoperability Quick Start Guide

2024 Promoting Interoperability Measure Specifications

Note that CMS may add additional documents to this resource library or update the documents throughout the year.

Finally, other sources of information regarding MIPS and MVPs include the following:

CMS Quality Payment Program Help Desk