January is when practices discover what they did not do last year. The 2023 MIPS submission window opened on January 2 and runs to April 1, 2024, and every year around now a practice manager opens the Quality Payment Program portal and finds that a measure they thought was being tracked has 40 percent data completeness. The 2023 year cannot be fixed. The 2024 year can, but only if the setup happens in the first quarter.
CMS finalized the 2024 rules in the Physician Fee Schedule final rule on November 2, 2023. Most of the headlines went to the conversion factor cut of about 3.4 percent, to $32.74, which took effect on January 1. The MIPS changes got less attention, and a few of them are traps for small practices. This article is for the practice with two to fifteen clinicians that has no quality department and one person who "does MIPS" on top of everything else.
Key takeaways
- The performance threshold stays at 75 points for 2024. Score below it and the penalty on 2026 Medicare Part B payments can reach 9 percent.
- Quality data completeness rises from 70 to 75 percent. A measure that misses it scores zero, however good the performance rate looks.
- The Promoting Interoperability reporting period doubles to 180 continuous days, so anything broken has to be fixed by mid-year. Small practices of 15 or fewer clinicians are automatically reweighted out of PI unless they choose to report it.
- There are now 16 MIPS Value Pathways. Single-specialty practices should look; multispecialty groups usually should not.
- Check eligibility for every clinician in the QPP portal before spending a single staff hour.
The changes that matter
| Item | 2023 | 2024 | Why it matters |
|---|---|---|---|
| Performance threshold | 75 points | 75 points | CMS proposed 82 and backed off. Score under 75 and you take a negative adjustment in 2026, up to 9 percent |
| Data completeness (Quality) | 70 percent | 75 percent | Each measure must include at least 75 percent of eligible patients across all payers, not just Medicare |
| Promoting Interoperability reporting period | 90 continuous days | 180 continuous days | You can no longer pick your best quarter; the latest start date is around July 4 |
| MIPS Value Pathways available | 12 | 16 | More specialties have an MVP option; traditional MIPS still available |
| Category weights | Quality 30, Cost 30, PI 25, IA 15 | Same | Cost is scored from claims; you cannot report your way out of it |
| Exceptional performance bonus | Ended with the 2022 performance year | None | There is no extra pool for high scorers; the upside is only the budget-neutral adjustment |
The payment adjustment for the 2024 performance year applies to 2026 Medicare Part B payments, and it remains budget neutral: the positive adjustments are funded by the penalties, so the upside is usually small. Most small practices are playing to avoid the penalty, and we think that is the right framing. A practice with $600,000 in annual Part B allowed charges that scores 40 points is looking at a penalty in the tens of thousands of dollars in 2026. The same practice at 76 points gets a small positive adjustment. The difference between those two outcomes is almost always setup, not effort.
Data completeness at 75 percent is the trap
Here is what goes wrong. A practice selects "Controlling High Blood Pressure" as a quality measure. The EHR shows a performance rate of 71 percent, which looks fine. But the denominator only counts patients where the EHR captured a qualifying blood pressure in a structured field. Patients whose BP was typed into the note as free text are missing. If those missing patients push the reported denominator below 75 percent of the true eligible population, the measure fails data completeness and scores zero, not 71 percent.
Put numbers on it. The practice has 1,200 patients aged 18 to 85 with a hypertension diagnosis and at least one qualifying visit in the year. That is the true eligible population. The EHR measure report shows 840 patients in the denominator, because 360 patients had their blood pressure recorded only in free text or not at all. Completeness is 840 divided by 1,200, or 70 percent. Under the 2023 rule that passed. Under the 2024 rule it fails, and the measure contributes nothing. To pass, the practice needs at least 900 of those 1,200 patients in the denominator, which means finding 60 more patients whose BP goes into the structured vitals field. In most practices that is a nursing workflow fix, not a software problem.
The fix is dull and specific: for each of your six quality measures, pull the measure's eligible population from the EHR, compare it with a schedule-based count of patients who should qualify, and find out why they differ. Do this in February, not December. The practices that fail data completeness are almost never the ones with bad care; they are the ones where a clinical assistant documents the depression screen in a text box instead of the screening template.
The 180-day PI period
The Promoting Interoperability category now requires 180 continuous days within the calendar year. Practices used to choose a clean 90-day window in the autumn after they had fixed their patient portal enrollment and their health information exchange connection. That option is gone. If a practice has a known problem with, say, the "Provide Patients Electronic Access" measure, it needs to be fixed by mid-year at the latest, and realistically by the end of March so there is a buffer.
The 2024 PI measure set also has two required attestations that trip people up: the annual security risk analysis and the SAFER Guides self-assessment, both of which must be completed during the calendar year. Query of a prescription drug monitoring program is a required yes or no measure this year, not a bonus. And the public health measures require active engagement with an immunization registry and electronic case reporting, with exclusions available where the state cannot accept the data. Write the list of your measures on one page with the date each was last confirmed working.
One correction to something we hear constantly: small practices do not need a hardship exception application for PI. A practice with 15 or fewer clinicians under its TIN is automatically reweighted, and the 25 percent moves to the other categories, mostly to Quality. If a small practice submits PI data anyway, CMS scores it. So the decision for a small practice is not "can we get out of PI" but "is our PI score likely to help or hurt". A practice whose EHR handles the measures cleanly often does better reporting PI than having its Quality score weighted at 55 percent. A practice that struggles with the portal and HIE measures should let the reweighting happen and put the time into Quality.
MVPs: should a small practice switch?
The 16 MVPs for 2024 cover primary care, several surgical specialties, cardiology, nephrology, ophthalmology and others. Reporting through an MVP means fewer quality measures (four instead of six), a population health measure calculated by CMS, and a more relevant cost measure set. For a single-specialty practice whose specialty has an MVP, we think it is worth a serious look. For multispecialty groups, traditional MIPS is usually still simpler because one submission covers everyone.
MVP registration runs from April 1 to December 2, 2024. You do not have to decide in January, but you should know by the end of the first quarter which measures you would report under each path, because the data collection setup differs. A three-physician nephrology group, for example, can compare the four measures in the kidney health MVP against the six it reported last year and see immediately whether its EHR captures them.
Check whether you are required to report at all
The low-volume threshold has not changed. A clinician or group is excluded from MIPS if, during the determination period, they bill $90,000 or less in Medicare Part B allowed charges, or see 200 or fewer Part B patients, or provide 200 or fewer covered professional services. Meeting any one of those excludes you. Log in to the QPP portal, enter each clinician's NPI and check eligibility status. Every year we meet practices spending real staff time on MIPS for clinicians who are not required to participate, and practices that assume they are excluded when they are not.
Two wrinkles. A clinician excluded individually may still be included if the practice reports as a group and the group exceeds the threshold. And a clinician who joined the practice during the year may be excluded under the new TIN for 2024 even if they reported elsewhere in 2023. Check each NPI under each TIN, and write the result down with the date you checked it.
Finish 2023 first
None of the 2024 setup matters if the 2023 submission is late. The window closes at 8 p.m. Eastern on April 1, 2024. Before you submit, confirm three things: that every measure meets the 70 percent completeness rule that applied to 2023, that the Improvement Activities attestation covers a continuous 90-day period with documentation on file in case of audit, and that the PI attestations for the security risk analysis and the SAFER Guides are dated in 2023. If a measure is going to fail completeness, submitting it still counts as reporting; leaving it out may cost you the small-practice bonus points that come with submitting the category.
Questions we hear
Is a 75-point score realistic for a small practice?
In our experience, yes, for a practice that picks measures its EHR captures well and keeps the data flowing all year. Small practices also get a six-point bonus in the quality category for submitting at least one measure, and their Improvement Activities are double weighted, so one high-weighted activity or two medium-weighted activities earns full credit. The practices that struggle are the ones that pick measures in December.
Does MIPS matter if we are joining an ACO?
Clinicians in a Shared Savings Program ACO report quality through the ACO under the APM Performance Pathway. Confirm with the ACO who submits what; do not assume. We have seen practices report twice and practices report not at all, both because nobody asked.
Can PCMH recognition help?
A practice with current PCMH recognition receives full credit for the Improvement Activities category, which is 15 percent of the score, without reporting individual activities. If you are already doing the work, the recognition is worth having for this reason alone. Our PCMH recognition service and annual review teams see this every year, and the timing question is simple: recognition must be in place for the performance year you are claiming.
What to do this quarter
- Confirm eligibility for every clinician in the QPP portal, individually and as a group, and record the result.
- Finish the 2023 submission before April 1. Do not leave it to the last week; the portal gets slow.
- Pick the 2024 quality measures, or the MVP, and run the eligible population check for each measure against a schedule-based count.
- Decide whether to report PI or accept the automatic reweighting, and if reporting, run the readiness check now: security risk analysis dated in 2024, SAFER Guides, patient portal access rates, e-prescribing, PDMP query, HIE connection, registry status.
- Look at last year's Cost category feedback. Cost is 30 percent of the score and comes from claims. If your Total Per Capita Cost or an episode-based measure scored poorly, the fix involves referrals and admissions, not documentation.
- Decide who owns MIPS. One named person, with a monthly check of measure rates. Practices where "the EHR handles it" are the ones that discover the 40 percent completeness in January.
