Want an Increase in Medicare Payment? Participate in MIPS

September 17, 2018
Rick Gawenda

Automatic annual increases in Medicare payment for outpatient therapy services is coming to an end after 2019 unless you participate successfully in the Merit-Based Incentive Payment Program (MIPS). Due to the passage of the Medicare Access and Chip Reauthorization Act of 2015, providers of outpatient therapy services received an annual update of 0.5% from July 2015 through 2019. For calendar years 2020-2025, there will be no update to the conversion factor that CMS uses to determine the payment amount for each CPT code paid under the Medicare Physician Fee Schedule. For 2026 and beyond, providers who participate in alternative payment models will have an annual update of 0.75% and all others will have an annual update of 0.25%.

Now for the bad news. Only physical therapists (PTs) and occupational therapists (OTs) in private practice (submit claims on a 1500 claim form) are eligible to participate in MIPS beginning in 2019 according to the proposed rule released by CMS on July 12, 2018. In 2019, if PTs and OTs are successful in MIPS reporting, they can be eligible for a positive payment adjustment up to 7% in calendar year 2021. In 2020, if PTs and OTs are successful in MIPS reporting, they can be eligible for a positive payment adjustment up to 9% in calendar year 2022.

Unfortunately, non-private practices (submit claims on a UB-04 claim form) are not eligible to participate in the MIPS program. This means as of the writing of this article, non-private practices will see no increases in their Medicare payment from 2020 through 2025.

I will be providing a webinar on September 26, 2018 to assist PTs and OTs in their preparation to get ready for MIPS in 2019. This webinar will assist physical therapists and occupational therapists in private practices, office managers, administrators and owners of private practices, and billers and billing companies of private practices in their preparation for possibly being MIPS eligible in calendar year 2019. This webinar will teach participants the 4 categories of MIPS and what is included within each category, how each category is weighted that then determines your final score, different ways to participate in MIPS, payment adjustments based on your score, low-volume thresholds that may give private practices the opportunity to not be required to participate in MIPS and the low-volume opt-in option.


At the conclusion of this webinar presentation, participants will be able to:

  • List the 4 categories in the 2019 MIPS program and how each category is weighted
  • Recite how MIPS eligible clinicians can report the data to CMS
  • Explain the 2-phase Determination Period and how it will determine if you must participate in MIPS to avoid a negative payment adjustment
  • Differentiate the 3 options available to participate in MIPS
  • List the 3 low-volume thresholds that would exclude a MIPS eligible clinician from being required to participate in MIPS
  • Explain the low-volume opt-in option available to physical and occupational therapists in private practice

For additional information on this webinar and to register, click HERE.

Thank you for reading this article.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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    1. PTAs and OTAs do not submit claims to the Medicare program. They bill under the NPI of the supervising therapist in a private practice setting.

  1. They are going to shaft us once again and not give us increases for 5 years! That is outrageous.

  2. Can PTs who so not meet the minimum threhsold still opt into the MIPS and be eligible for the increase in payment?

    1. It would be the PT since it’s the individual who CMS is looking at regarding must they participate in MIPS

  3. On page 17 of your slides regarding Improvement Activities, groups with fewer than 15 participants only need to attest to completing 2 activities. however, to earn full credit for those 2 activities, what’s the combination of weighted activities? Can it be 2 medium weighted and still get full credit?

    1. You would need to report as a group and not individual If reporting as a group and you have 15 or fewer clinicians, you would need to report 1 high-weighted improvement or 2 medium-weighted activities.

  4. Is there a deadline date to register for “opt-in” option for individuals and/or groups if want to participate in 2019?

    1. We will know when the final rule is released. In 2018, there was no required registration if reporting via a registry. In 2019, CMS is allowing claims-based reporting for small practices (15 or fewer eligible clinicians) so we will have to see how CMS will be notified they want to report as a group.

    1. Depends if you exceed the 3 thresholds. If yes, mandatory. If only exceed 1-2, you can decide whether to opt in or not.

    1. MIPS is only for practices that submit claims on a 1500-claim form and at this time, there are no plans to bring MIPS to providers who submit claims on a UB-04 claim form.