TABLE OF CONTENTS

Get Started with MIPS Reporting

Stay Informed


For the latest official guidance, deadlines, and program tools, please visit qpp.cms.gov.  We recommend bookmarking this site as your primary and most consistent resource for all Quality Payment Program updates.


Understand MIPS Program Requirements

Eligibility & Reporting Types

Physical therapists, occupational therapists, and speech-language pathologists are required to participate in MIPS if they exceed the Low-Volume Threshold, which is made up of three criteria based on the volume of Medicare Part B services they render. This threshold evaluates a clinician's total allowed charges, the number of unique Medicare beneficiaries they treat, and the total number of covered professional services they provide. These metrics are monitored across two 12-month Determination Periods.


Clinicians are opt-in eligible if they exceed 1 or 2 of the criteria, but not all 3. 


Learn more here: How is MIPS Eligibility Determined?


Group Reporting: The data for all NPIs within a TIN is aggregated and submitted. Group participation is never mandated. 

Individual Reporting: The data reported is for one clinician in an NPI/TIN combination. Participation is mandated at the Individual level if the Low-Volume Threshold is reached (i.e. exceeds all 3 criteria). 


MIPS Categories

Quality: The Quality category aims to assess the quality of care being provided to patients as measured by Quality measures. WebPT members have the option to choose from two types of Quality measures: Process Measures and Outcome measures. 

Improvement Activities: The Improvement Activity category aims to promote enhancing practice workflows, patient engagement, and care coordination

Cost: The Cost category aims to manage the total cost of care of Medicare beneficiaries. This category is calculated by CMS based on claims data and does not require data submission.

Promoting Interoperability: The Promoting Interoperability category focuses on leveraging Certified EHR Technology (CEHRT) to modernize the way health data is handled.


For more information about MIPS categories, visit https://qpp.cms.gov/get-started/what-is-mips/about-mips.


Special Statuses

A Special Status is an automatic designation assigned by CMS to clinicians or practices that face unique challenges due to their size, location, or the nature of their patient interactions. There are seven different Special Statuses that can be assigned. Small Practice is a Special Status designation commonly seen for WebPT members. 


Small Practice: defined as 15 or fewer providers connected to the TIN. This is not determined by how many providers you have reporting or required to report, but the total number of providers in your TIN. If you are considered a small practice, this changes the weights of your reporting categories and modifies some of your reporting requirements. 


Learn more here: Special Statuses


Choose Your Quality Measures 

  • Identify the measures you find are relevant to your practice and patient population. 
  • You are required to submit at least 6 Quality Measures when participating in Traditional MIPS, but you can submit more if you would like. CMS will choose the top 6 scoring measures to determine your final Quality score. 
  • WebPT members have the opportunity to report on 18 Quality Measures. To review the Quality Measure specifications click here: 


Choose Your Improvement Activities 

  • Choose 2 Improvement Activities to complete for the performance year. If you are considered a small practice only 1 activity is required. 
  • Review the Validation Criteria resource on the QPP website to understand how to complete these and the documentation you need to keep in the event of an audit. 
  • Improvement Activities must be performed over a period of 90 consecutive days. If you submit as a group, 50% of the NPIs associated with your TIN must complete the activities.
  • You can review the available Improvement Activities using the QPP's Explore Measures & Activities tool. 

Access your Accounts 

  • EMR & Keet - document your Quality Measures 
  • Patient360 - track and optimize your performance throughout the year 
  • QPP - review eligibility, special statuses and performance feedback information 

 

If you need to create a QPP account, review the QPP Access User Guide.


Configure your Patient360 Portal 

  • Document your practice details and any reporting factors that influence your final score in the Clinic Information section of your Patient360 portal. This ensures your estimated scoring in the portal most accurately reflects the different scenarios that impact the final score CMS assigns.
  • Add any additional members of your team who need access to your performance data: Add a User to Patient360. 

Collect Your Data

Complete Quality Measure Documentation

  • Use WebPT and Keet to complete all documentation for the Quality measures you chose. 
  • Collect all required MIPS data points as part of your daily documentation flow. 
  • Ensure you are utilizing the platforms correctly so that all of the necessary data is captured for each encounter. 
  • Process Measures: document in the necessary fields in the EMR SOAP note, then complete the attestation in Keet. Do this for each eligible encounter. 
  • Outcome Measures: document the patient-reported outcome (PRO) measure and risk adjustment fields (if applicable) in Keet. Ensure you collect the measure at least twice, once at initial evaluation and once at discharge. 
    • Success Tip: Aim to gather more frequent PRO measures than just the minimum required at initial evaluation and discharge. Getting three or more total PRO measures completed is associated with better outcomes! This gives the clinician and patient more opportunity to communicate and, when applicable, adjust the care plan to best optimize improvements in patient-perceived functional status.


Review the following WebPT Resources to learn more about your documentation workflows:
Scheduler Workflow
Provider Workflow
EMR Process Measure Fields


Monitor Performance

  • Utilize the Patient360 dashboard to continuously monitor your MIPS performance and estimated scores throughout the Performance Year. 
  • Correct any data discrepancies you see as you identify them, don’t wait until submission time.
  • In addition to your ongoing and regular review, Patient360 will deliver four feedback reports to your email prior to the submission of your data to CMS.

Add Your Improvement Activities to the Patient360 Portal 

Get Ready for Final Submission

Attest to your Completed Improvement Activities

Complete Promoting Interoperability (PI) Requirements

  • Add your Small Practice status OR upload your PI Hardship Exception approval letter to your Patient360 portal.
  • Configuring these within your Patient360 account allow you to visualize how a Promoting Interoperability re-weight may impact your MIPS estimated score.


PI Hardship Exception applications are due on December 31, 2026 at 8 PM Eastern 


Verify Data Accuracy 

Group Consent

Individual Consent 

Submit MIPS Data