Special Statuses

The Quality Payment Program automatically assigns special statuses to Merit-based Incentive Payment System (MIPS) eligible clinicians, practices, and virtual groups who meet certain criteria. If you receive a special status, your reporting requirements may be affected.

How do I Know if I’m Special Status?

If you’ve been automatically assigned a special status, it will be added to your eligibility profile in the QPP Participation Status Tool. If you’ve been assigned a special status in Segment 2, it may not appear in the lookup tool until the submission window is open in 2020.  If you think you should have a special status or believe there is a mistake in your special status designation, contact the Quality Payment Program.

How is Special Status Determined?

To determine if a MIPS eligible clinician, practice, or virtual group will receive a special status, CMS retrieves and analyzes Medicare Part B claims data.  Special statuses are calculated if you reach the requirements for at least one of the MIPS determination segments.

ASC-based

If a clinician, practice, or virtual group is ASC-based, they qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be reallocated to Quality.  

A clinician will receive this special status if the MIPS eligible clinician furnishes 75% or more of their covered professional services in sites of service identified by Place of Service (POS) code 24.  A practice will qualify if all MIPS eligible clinicians associated with the practice are designated as ASC-based. Virtual groups qualify if all MIPS eligible clinicians associated with the virtual group are designated as ASC-based.

Hospital-based

If a clinician, practice, or virtual group is hospital-based, they qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be reallocated to Quality.  In this category, the special status qualifies as follows. For a clinician, the MIPS eligible clinician furnishes 75% or more of their covered professional services in a hospital setting. For a practice, all MIPS eligible clinicians associated with the practice are designated as hospital-based.  For a virtual group, all MIPS eligible clinicians associated with the virtual group are designated as hospital-based.

Non-patient Facing

A clinician, practice, or virtual group will earn 2x the points for each improvement activity they submit.  Individual clinicians will also qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be reallocated to Quality Non-patient facing practices and virtual groups do not automatically qualify for reweighting of the PI category unless 100% of their MIPS eligible clinicians qualify individually.  The qualifications in the category look like this: For an individual, the MIPS eligible clinician has 100 or fewer Medicare Part B patient-facing encounters (including telehealth services). For a practice, more than 75% of the clinicians billing under the practice’s TIN meet the definition of non-patient facing. And for a virtual group, more than 75% of the clinicians billing within a virtual group meet the definition of a non-patient facing.

Small Practice

This category has been updated for 2019.  A clinician, practice, or virtual group will earn 2x the points for each improvement activity they submit. Clinicians, practices, or virtual groups who submit at least one Quality measure will also receive 6 bonus points in the Quality performance category.  Here’s how the qualifications line up for this category: The MIPS eligible clinician is one of 15 or fewer clinicians billing under the practice’s TIN. For a practice, 15 or fewer clinicians bill under the practice’s TIN. Virtual groups need to have 15 or fewer clinicians bill under TINs that participate.

HPSA

A clinician, practice, or virtual group will earn 2x the points for each improvement activity they submit.  Qualifications look like this: The MIPS eligible clinician practices in an area designated as an HPSA.  Qualifying practices are a group that has at least one practice site under its TIN designated as an HPSA.  A virtual group qualifies if 75% or more of the clinicians billing in the virtual group are designated as an HPSA.

Rural

A clinician, practice, or virtual group will earn 2x the points for each improvement activity they submit.  Special status qualifications look like this: The MIPS eligible clinician is associated with a practice in a zip code designated as rural using the most recent Health Resources and Services Administration (HRSA) HPSA data.  For a practice, 75% or more of the clinicians billing under the practice’s TIN are in a zip code designated as rural using the most recent HRSA HPSA data.  And for virtual groups, 75% or more of the clinicians billing in the virtual group are in a zip code designated as rural using the most recent HRSA HPSA data.

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