MIPS Series: part 1 of 3
This article is the first in a series of three and provides valuable insight regarding the Merit-based Incentive Payment System (MIPS) and its impact on radiology.
Be sure to review the rest of the articles in the series:
- Part 2: MIPS: How Radiology Scores are Calculated
- Part 3: MSN QCDR Measures 2025
MIPS in 2025
Performance Year 2025 is the Merit-based Incentive Payment System’s (MIPS) ninth year and much of what CMS has finalized appears to be very favorable to the industry. Proposals that would have been unfavorable to the industry, such as increasing the penalty threshold, were generally not finalized. Radiologists have continued to embrace the MIPS program and their success in fulfilling the MIPS quality measures documentation requirements have yielded both upside and downside with respect to their Medicare Part B payment adjustments.
Although the MIPS program is leaning towards an emphasis on outcome measures associated with a) health equity and the reduction of disparities, and b) electronic and digital capture, there are still plenty of quality process measures in the MIPS program. While the positive payment adjustments for the 2023 performance year were much lower than projected, the reward vs risk ratio continues to be high, given that the penalty for not reporting at all is -9 percent.
The Upside of MIPS
The upside is a majority of eligible clinicians have not only avoided penalties, but many have received substantial positive payment adjustments.
Clinicians who achieved a perfect score in performance year 2023 are currently enjoying a +2.15 percent adjustment in calendar year 2025. Financial projections for performance year 2024 are expected to be similar. Extreme and Uncontrollable Circumstances exemptions for COVID-19 were no longer available in 2024, however, the devastating hurricanes in the southeast U.S. and the Change Healthcare data breach have provided many eligible clinicians with the option to avoid submission. Given that MIPS is a budget-neutral program, lower numbers of poor performers in the program have yielded lower positive payment adjustments for those who have exceeded the 75-point threshold.
Big news for performance year 2025, and in preparation for proposed 2026 MIPS Value Pathways (MVP) submissions, is that several quality measures that were previously devalued to 7 points will be scored according to new topped out benchmarks.
The Downside of MIPS
Although several of the previously devalued measures will be eligible for 10 points in 2025, unless a practice uses IR measures it is difficult to receive a perfect quality score. The diagnostic radiology measures that will yield 10 points with perfect performance in PY2025 include:
- Measure #360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
- Measure #364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
- Measure #405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions
- Measure #406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
CMS has removed the CT dose reduction technique measure (#436) and has replaced it with an electronically-captured measure that requires software to be loaded onto all CT equipment. Many hospital-based providers may find this to be a challenge since hospitals may be reluctant to allow a third-party vendor to add software to their equipment, especially since there is no direct benefit to the hospital and the security of patient data is a high priority.
Cost Performance Category
An unfortunate downside of MIPS is evident when clinicians use NPs or PAs to perform outpatient E&M visits. While using mid-level providers rather than an Interventional Radiologist to perform pre- and post-surgical screenings is a financial savings to the group, it puts the group at risk for triggering the Total Per Capita Cost (TPCC) measure. This measure is designed for primary care services but, since NPs/PAs are included in the specialty code description, they are eligible for this measure. Historically, the dollars associated with these patients is significantly higher than other specialties that trigger the measure, making the points for this Cost measure extremely low.
How Can Radiologists Succeed in 2025?
The maximum payment adjustment in 2025 is legislated by Congress and is +/-9 percent. Quality and Cost performance categories are each 30 percent, with Promoting Interoperability and Improvement Activities holding steady at 25 percent and 15 percent respectively.
It is important for clinicians to understand how they can succeed under MIPS.
- Be thoughtful about selecting measures
- Track at least 6 measures that have a published benchmark (example: #145)
- Track at least 6 measures that are not devalued (example: #405)
- Implement and improve workflows so that all measures can meet the required documentation elements
- Use templates, macros, and/or structured reporting
- Communicate with and educate all clinicians about the measures the group has selected and their documentation specifications
- Be sure to train new clinicians who join the group mid-year
- Aim for perfect performance on most, if not all, of your quality measures
- Monitor all measures regularly throughout the year to identify and correct deficiencies
CMS has signaled that its plan is to shift to MIPS Value Pathways (MVPs) and has proposed radiology MVP candidates for the 2026 performance year. The MVPs proposed include the specialties of diagnostic radiology, interventional radiology and vascular surgery.
Qualified Registries vs. Qualified Clinical Data Registries
The fact that national MIPS measures are topping out and being eliminated leads to a discussion about the differences between Qualified Registries and Qualified Clinical Data Registries.
A Qualified Registry is limited to reporting national measures only [1]. A Qualified Clinical Data Registry (QCDR), however, can report both national measures and QCDR (non-national) measures.
QCDR measures must be reviewed and approved by CMS annually and, to report a QCDR measure, a radiologist must be reporting through a QCDR. QCDR measures that have been approved by CMS are specific to the QCDR submitting the measure for approval; however, it is possible for QCDRs to license measures to or from other QCDRs.
QCDRs, such as those of MSN Healthcare Solutions and the American College of Radiology, develop and submit QCDR measures to CMS on a regular basis. The advantage to the QCDR clients is that in year one of the program, the measures are valued at 7 points (minimum), even if performance is poor. If a retro-benchmark is given to a new measure, the measure would be worth 10 points.
[1] National measures are numeric IDs only, e.g. measure #364 is a national measure.
MIPS Article Series
This article is #1 of 3 in our MIPS series. Be sure to check out the rest of the articles in the series:
- Part 2: MIPS: How Radiology Scores are Calculated
- Part 3: MSN QCDR Measures 2025
Barbara Rubel
MBA, FRBMA
Senior Vice President, Marketing & Client Services
Barbara has been a leader with MSN Client Services since 1998. Her extensive background in strategic planning, market research, healthcare marketing and managed care negotiations provides a wealth of information to support MSN Clients.
Barbara has also been highly involved in industry organizations, serving as President of the Radiology Business Management Association (RBMA), the Georgia RBMA, and the Florida RBMA. In addition, she chaired the influential RBMA Federal Affairs Committee and the RBMA Technology Task force and was a member of the RBMA Data Committee. Her work on behalf of radiology has earned her the RBMA Special Recognition Award (2010), the RBMA Global Achievement Award (2013), and she is a Fellow of the RBMA.
Diana Stillwell
MHSA, CPHQ, CNMT
MSN Director, Quality Payment Programs & QCDR
Diana Stillwell, MHSA, CPHQ, CNMT, brings a wealth of experience to her position as MSN Director of Quality Payment Programs & QCDR. She worked on the clinical side of the business as a technologist and supervisor for more than 21 years and served nearly 7 years as a radiology practice director of quality improvement and risk management before joining MSN almost three years ago. She works closely with MSN senior leaders and client managers on the MIPS team to provide guidance and education to client practices with the goal of improving their reporting processes and optimizing performance in the MIPS program. In addition, she collaborates with MSN’s coding leaders to implement and/or edit workflow processes for new and modified measures.
This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document. All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.
