Who Will MIPS Apply To?

August 29, 2018
Rick Gawenda

The Physician Quality Reporting System (PQRS) that physical, occupational and speech therapists have had to participate in the past several years to avoid a payment reduction ended on December 31, 2016. PQRS was replaced with a new program called Merit-Based Incentive Payment System (MIPS) that combines 3 previous programs and adds one additional category.

Providers participating in MIPS will have to show they provided high quality, efficient care supported by technology by sending in information in the following categories:

  • Quality (Replaces PQRS)
  • Improvement Activities (New Category)
  • Promoting Interoperability (Replaces the Meaningful Use Program)
  • Cost (Replaces the Value-Based Modifier)

In 2017 and 2018, physical therapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) in private practice, either therapist owned or physician owned, were not mandated to participate in MIPS. However, in 2019, this is all changing. The Centers for Medicare and Medicaid Services (CMS) is proposing to add physical therapists and occupational therapists in private practice as eligible professionals who would be required to participate in MIPS unless they meet at least one of  the low-volume thresholds.

So MIPS will only be applicable to physical therapists and occupational therapists that provide outpatient therapy services in a private practice setting (i.e. submit claims on a 1500-claim form). MIPS WILL NOT apply to physical therapists and occupational therapists that provide outpatient therapy services in a nonprivate practice setting (i.e. submit claims on a UB-04 claim form) such as skilled nursing facilities, rehabilitation agencies, comprehensive outpatient rehabilitation facilities, home health agencies doing Part B in the home and hospital outpatient departments.

Please join us as Gawenda Seminars & Consulting, Inc. presents “MIPS is Coming in 2019: Lets Begin to Get Ready!” webinar conference on Wednesday, September 26, 2018 from 1:00pm – 2:30pm EST. This webinar will begin the preparation of the participants to understand the 2019 MIPS program and its implication for physical and occupational therapists in private practice who submit claims on a 1500-claim form. This webinar is not applicable for outpatient therapy billed on the UB-04 claim form. For the full webinar description, objectives and to register, click HERE.

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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. Is there any information available on what will be the plan for hospital outpatient departments?

  2. We are a certified Rehab facility that bills on a UB-04. I have taken webinars etc on MIPS and I understand that the physician fee scale will not increase for 3 years for the therapy practices that are required to follow MIPS. My question is will the fee schedule increase as usual for those of us that file on UB-04 forms? Or will we have to wait the 3 years along with everyone else?

    1. The last increase to the fee schedule will occur in 2019 and there will be no increases to the fee schedule from 2020-2025 for all settings paid under the Medicare Physician Fee Schedule. This would include hospitals, Rehab Agencies and SNFs