Participants in MIPS have a performance threshold which is the minimum points needed to prevent the negative payment adjustment to Medicare Part B claims in 2022. Last year MIPS participants were required to have a total of 30 points to meet this performance threshold. This year the performance threshold is 45 points.

Without an electronic health record (EHR) it can seem impossible to meet the minimum requirements this year but don’t give up! It’s easier than you may think.

First the good news, you only have to report on two of the four categories. There is a Hardship Exception for Promoting Interoperability category and the Cost category. Then look at your options for quality improvement and improvement activities. Here are recommendations for getting started:

Promoting Interoperability:

Apply for the hardship application which is now open.

  1. The hardship is automatic for some providers (i.e. NPs, hospital based, etc.) – check your status on the QPP participation status lookup tool
  2. Increases the weight of your quality measures from 45 to 70 percent
  3. Go to about the exception application page to see if you qualify


  1. 15% of your score
  2. No data to report – data is calculated based on claims and can be reviewed by logging into the QPP website and going to MIPS feedback
  3. 2020 cost measures can be reviewed on the QPP website along with the quick start guide

Quality Category:

  1. Are you currently collecting quality data for other organizations or purposes? Let us know what data you are collecting so we can discuss how the processes you currently have in place may help to meet MIPS requirements.
  2. Select measures from the 2020 Quality Measure List that meet data completeness (meaning 70 percent) and/or high weighted and outcome measures when possible – this gives you more points/possible bonus points. Not sure which measures meet this year’s requirements? Review your specialty measure set and report on six measures in the set or if the set contains less than six you should report on all measures in the set. Still looking for measures? Ask how the Single Source Document can be used to select measures based on codes you currently bill.
  3. Use multiple submission methods – report measures that you can via claims. Look for N620 on your re-admittance advice or explanation of benefits after filing to ensure codes are processed. Still need points? Use the registry measures and report through a registry.

Improvement Activity:

You can review a complete list of 2020 improvement activities (IA) here.

  1. Look at current processes and see what you already have in place that can be improved.
  2. Review activities that can impact your quality measures for improved scoring on that quality measure.
  3. Look for activities that can help you reduce cost.

Examples of processes you may already have in place are IA PSPA 6 Consultation of the Prescription Drug Monitoring Program or IA AHE 1 Engagement of New Medicaid Patients and Follow up. Remember IA is for a 90 day period so you still have time to identify the activity and put your process in place.

We have free resources and an online tool to make this process easier. We are always here to assist! Walking you through this process is part of the free service we offer our providers. For additional questions and help please contact us at 844-205-5540 Monday – Friday 8:30am – 5pm (Central Time), through or log into your free Providers exchange account to request assistance today!