1. What Is MIPS and Why It Matters
MIPS — the Merit-based Incentive Payment System — is the primary reporting track within the CMS Quality Payment Program (QPP), established under MACRA (Medicare Access and CHIP Reauthorization Act of 2015). It replaced three legacy CMS programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier, and the Medicare EHR Incentive Program (Meaningful Use).
MIPS applies to eligible clinicians who bill Medicare Part B above the low-volume threshold — currently $90,000 in Medicare Part B allowed charges per year, or more than 200 Medicare Part B patients per year. Clinicians below both thresholds are exempt. Clinicians above either threshold are subject to MIPS.
The stakes in 2026: a final MIPS score below the performance threshold triggers a negative payment adjustment of up to −9% on all 2028 Medicare Part B claims. A score above the threshold earns a positive adjustment up to +9%, plus an exceptional performance bonus if the score exceeds the additional performance threshold. For a practice billing $400,000 annually in Medicare Part B, that is a $72,000 swing.
2. The 2026 Performance Year Timeline
3. Quality Category (30%): Measure Selection Strategy
The Quality category is worth 30% of your composite MIPS score. You must report on 6 measures (for individual or group reporting), including at least 1 outcome measure OR 1 high-priority measure if no outcome measure is applicable to your practice. If fewer than 6 measures apply to your patient population, you report on all applicable measures.
Quality measure performance is benchmarked against national distributions of all MIPS eligible clinicians who reported the same measure. Your decile performance within the national distribution determines your points (0–10 scale per measure). Ten points per measure × 6 measures = 60 possible Quality points, normalized to 0–100 for the category score.
4. Cost Category (30%): What CMS Calculates for You
The Cost category requires no data submission. CMS calculates it entirely from Medicare claims. The primary measure is Medicare Spending Per Beneficiary (MSPB), which measures the cost of care around an acute episode of care from 3 days before through 30 days after a hospital discharge. CMS also calculates Total Per Capita Cost (TPCC) for clinicians who manage a substantial portion of a beneficiary's care.
Because you cannot submit data for the Cost category, your strategy is clinical: efficient care coordination, appropriate prescribing, post-discharge follow-up that prevents costly readmissions, and referral patterns to cost-effective specialists all influence your Cost category score indirectly.
Vizier models your estimated Cost category performance using your current post-discharge management patterns, specialist referral costs, and readmission rates — giving you a directional view of where you stand before CMS releases final scores.
5. Promoting Interoperability (25%): Technical Requirements
Promoting Interoperability (PI) is worth 25% of your composite score and is the category most likely to generate a zero if overlooked. Failing to report PI data results in a PI score of zero, which severely depresses your composite score regardless of Quality and Cost performance.
Clinicians using 2015 Edition Certified EHR Technology or later are eligible to report PI. Hospital-based clinicians (those who furnish 75%+ of covered services in a hospital setting) may be automatically reweighted to zero for PI — with the PI weight redistributed to other categories. Consult your EHR vendor to confirm your certification edition.
6. Improvement Activities (15%): Point Values and Selection
Improvement Activities (IA) is worth 15% of your composite score. You earn points by attesting to completing clinical improvement activities over a continuous 90-day period during the performance year. The point requirement is 40 points for most clinicians, reduced to 20 points for small practices (fewer than 16 clinicians) and rural or geographic HPSA practices.
Two high-weight activities (40 points) or four medium-weight activities (40 points) or any combination totaling 40 points satisfies the full IA requirement. Small practices can meet the requirement with one high-weight activity or two medium-weight activities (20 points total).
7. Composite Score Calculation Formula
+ (Cost Score × 0.30)
+ (PI Score × 0.25)
+ (IA Score × 0.15)
= Composite MIPS Score (0–100)
Each category is converted to a 0–100 scale before weighting is applied. The resulting composite score is a number between 0 and 100. CMS then maps your composite score to a payment adjustment percentage using the performance threshold and exceptional performance threshold set for each program year.
Category reweighting: when certain categories are not applicable (e.g., hospital-based clinicians exempt from PI), the weight of that category is redistributed proportionally to remaining categories. This reweighting can significantly change the relative importance of Quality, Cost, and IA for affected clinicians.
8. Final Score to Payment Adjustment Mapping
The specific performance threshold and exceptional performance threshold for 2026 will be published by CMS in the final QPP rule (typically released in October–November of the performance year). CMS has historically increased the performance threshold annually. Plan your measure strategy to achieve a score well above the threshold, not just at it.
9. MIPS Value Pathways (MVPs)
MIPS Value Pathways (MVPs) are a streamlined reporting framework that replaces traditional MIPS for participating clinicians. Each MVP is a pre-defined set of specialty-specific quality measures, cost measures, PI requirements, and improvement activities grouped around a clinical area or condition.
Available MVPs include: Rheumatology, Stroke Care and Prevention, Heart Disease (including coronary artery disease and heart failure), Primary Care, Infectious Disease, Nephrology, Pulmonology, Oncology, and Emergency Medicine. CMS has signaled that traditional MIPS reporting will be phased out in favor of MVPs over the coming years.
Participants in MVP reporting are compared only against other MVP reporters in the same pathway, not the full MIPS eligible clinician pool. This can create scoring advantages or disadvantages depending on the performance level of your specialty peer group. Vizier models your projected score under both traditional MIPS and any applicable MVP before you choose your submission path.
10. Group vs Individual Reporting
MIPS eligible clinicians can report as individuals (single NPI) or as part of a group (single TIN with 2 or more clinicians). The reporting entity decision affects your denominator for quality measures, your eligible measure options, and the benchmarks against which you are scored.
- Scored on your own performance only
- Smaller denominators can limit measure options
- Physician-to-physician comparison possible
- Can opt into group reporting mid-year if group threshold is met
- Scored on combined TIN performance
- Larger denominators improve measure reliability
- One composite score for all TIN clinicians
- Group-level benchmarks used for scoring
11. Small Practice Considerations
Practices with 15 or fewer clinicians qualify as small practices under MIPS and receive several accommodations: reduced Improvement Activities requirement (20 points instead of 40), a 6-point floor in the Quality category to prevent zero scores from small denominators, and automatic reweighting of PI to zero (redistributed to Quality) if the practice submits an attestation of being a non-EHR user.
Additionally, low-volume threshold exemptions remain available: practices billing $90,000 or less in Medicare Part B allowed charges OR seeing 200 or fewer Medicare patients are excluded from MIPS. However, excluded practices may opt into MIPS voluntarily for performance feedback without payment consequences — a useful practice for those approaching the threshold.
12. How to Achieve the Exceptional Performance Bonus
CMS sets an additional performance threshold (above the standard performance threshold) that qualifying clinicians must exceed to receive the exceptional performance bonus. This bonus is funded from a $500 million pool appropriated by Congress for MIPS years 2019 through 2026, distributed proportionally among all qualifying clinicians.
To maximize your chance of earning the exceptional performance bonus: achieve maximum or near-maximum scores in all four categories, prioritize outcome measures in the Quality category (they carry more weight than process measures in the scoring algorithm), and ensure PI reporting is complete with all available bonus elements submitted. Practices that achieve 100 composite points are guaranteed to receive the exceptional performance bonus.
13. Common MIPS Mistakes
14. 2026 Data Submission Timeline and Action Steps
Successful MIPS performance is not a year-end activity. The practices that consistently achieve high composite scores operate a continuous monitoring cadence throughout the performance year.
Track Your MIPS Score in Real Time
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