MIPS Series: part 3 of 3
This article is the third 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:
QCDR Measures: MSN’s 2025 Offerings
MSN currently offers the following QCDR measures that have been approved by CMS for the performance year 2025:
10 Point Measures (7-10 points) **NEW**
| Measure ID | Measure Title |
|---|---|
| QMM31 | Solid Organ Injury Grading on CT/CTA for Blunt Abdominal Trauma (BAT) Patients **NEW** |
| QMM32 | Intracerebral Hemorrhage (ICH) Scoring on Non-Contrast CT Head **NEW** |
10 Point Measures (5-10 points)
| Measure ID | Measure Title |
|---|---|
| QMM26 | Screening Abdominal Aortic Aneurysm Reporting with Recommendations |
| QMM27 | Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts |
| QMM28 | Reporting Breast Arterial Calcification (BAC) on Screening Mammography |
10 Point Measures (0-10 points)
| Measure ID | Measure Title |
|---|---|
| MEDNAX55 | ASPECTS (Alberta Stroke Program Early CT Score) for Non-Contrast Suspected Acute Stroke |
| QMM17 | Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnextal Reporting and Data System (O-RADS) |
| QMM23 | Low Dose Cancer Screening Recommendation for CT of Chest with diagnosis of Emphysema |
| QMM24 | Acute Rib Fracture Numbering on Acute Trauma Patients |
| ACRAD15* | Report Turnaround Time: Radiology |
| ACRAD16* | Report Turnaround Time: Ultrasound |
| ACRAD17* | Report Turnaround Time: MRI |
| ACRAD18* | Report Turnaround Time: CT |
| ACRAD19* | Report Turnaround Time: PET |
| ACRAD25* | Report Turnaround Time: Mammography |
7 Point Measures (0-7 points)
| Measure ID | Measure Title |
|---|---|
| MSN13 | Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery Calcification Regional Distribution Scoring |
| MSN15 | Use of Thyroid Imaging Reporting & Data System (TI-RADS) in Final Report to Stratify Thyroid Nodule Risk |
| QMM16 | IVC Filter Management Confirmation |
| QMM18 | Use of Breast Cancer Risk Score on Mammography |
| QMM19 | DEXA/DXA and Fracture Risk Assessment for Patients with Osteopenia |
| ACRAD36 | Incidental Coronary Artery Calcification Reported on Chest CT |
| ACRAD37 | Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism |
| ACRAD41 | Use of Quantitative Criteria for Oncologic FDG PET Imaging |
Looking Ahead: MIPS in 2025 and 2026
Looking ahead to MIPS in 2026, the 2025 Medicare Physician Fee Schedule Final Rule has introduced MVPs for both Diagnostic and Interventional Radiology. The comment period ended on February 24, 2025 and the goal is to introduce both in 2026. Four radiology measures that have historically been devalued to 7 points are now worth 10 points in 2025 (#360, #364, #405, #406). A negative payment adjustment of -9 percent stays in place and has been static since performance year 2020.
The Composite Performance Score to avoid a penalty is, by law, the mean or the median of the average composite score across all eligible clinicians. CMS cannot set the bar other than to select either the mean or the median. CMS had proposed a penalty threshold of 82 points in the 2024 MPFS Final Rule, however, that proposal was not finalized. Thus, the penalty threshold stays at 75 points, where it has been since 2022. The estimated positive payment adjustment in 2026 is 2 percent. That said, look for CMS to propose an increase in the penalty threshold for performance year 2026. Even with the rebirth of 10-points for 100% performance on a few of the national measures, achieving perfect performance through a Qualified Registry is still very difficult. Perfect performance on 6 10-point measures is required for practices with more than 15 clinicians to achieve 60/60 for quality.
Exhibit A: Penalties, Penalty Thresholds and Payment Adjustments since 2017 (initial year of MIPS):
Exhibit B: Key Components of the 2025 MIPS Program
New Measure in 2025
A new national measure, measure #494, has been introduced in 2025. The description is Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography In Adults. It will measure the percent of CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality relative to evidence-based thresholds based on the clinical indication for the exam. This outcome measure is worth a minimum of seven points since it is new to the Program. A reminder that in 2025, if you report #494 and it is the only outcome measure you report, it will be scored as one of your top 6 measures, regardless of performance.
The following data elements are needed to calculate this measure:
- Image Quality Category (type of CT defined by CPT)
- CT Dose – Actual (dose length product)
- CT Global noise (hounsfield units)
It requires use of additional software to access primary data elements that are stored with radiology EHRs and translates them into data elements that can be used for the measure. This software is offered to clinicians at no charge by the measure steward, which is Alara Imaging, Inc.
Improvement Activities
The 2025 scoring has been simplified by removing activity weightings (high-weight and medium-weight). Clinicians who are defined as small practices, virtual groups, rural groups, are non-patient facing, or who provide services in a health professional shortage area must only attest to one activity. All others must attest to two activities.
MIPS Article Series
This article is #3 of 3 in our MIPS series. Be sure to review the rest of the articles in the series:
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.
