Low-volume Threshold: MIPS 2018

The Centers for Medicare and Medicaid Services (CMS) are beginning to recognize that solo and small practices are having difficulty meeting the requirements of the Merit-Based Incentive Payment System (MIPS).  As a result, they have expanded the low-volume threshold in 2018 (APAPO, 2017).  This is good news for psychologists because many of us will fall under the low volume threshold and not be required to report under MIPS.

In 2018, a psychologist will not have to report under MIPS if he/she treats 200 or fewer Medicare Part B beneficiaries or bills Medicare Part B for $90,000 or less in allowable charges.   This is 200 or fewer unique patients, not sessions.  Revenue from Medigap policies (secondary payers) or Medicare Advantage plans is not included in the $90,000 figure.  Thus, only revenue directly from Medicare Part B reimbursement is counted.  Also, patient’s that have Medicare Advantage plans are not included in the patient count. This means that if you saw 201 or more patients, but received less than $90,000, you still would not have to report.  Likewise, if revenue was over $90,000, but you saw 200 or fewer unique Medicare Part B patients, you would not have to report.

If you are in solo practice, it is very straight forward: you simply count your Medicare Part B patients and tally your Medicare Part B revenue.  If you are in a group practice, you may or may not have to report MIPS depending on how you are categorized (billed).

If you are categorized as being in a group practice it is not so clear.  If billing is done using your own NPI number but the group’s Tax ID number, then the cumulative Medicare Part B reimbursement of all members of the group practice might count toward the low volume threshold.  In this case, if revenue was over $90,000 (and 201 or more unique individual patients were seen) all members would be required to report under MIPS.

For further clarification and with the help of Diane Pedulla we asked CMS how an individual psychologist would be categorized (i.e., as an individual provider within a group or as part of a group) when using a billing service that uses the same Tax ID number for all the providers that are billed through that service.  We have not yet received a response but will update you as this information becomes available.

So,  currently it isn’t entirely clear how CMS tracks whether you are part of a group or an individual within a group, especially if you are an independent contractor (personal communication with Diane Pedulla, 2018).   You may very well be able to determine for yourself how you want to categorize yourself.  The obvious benefit of falling under the low volume threshold is that you don’t have to worry about MIPS and you will not receive a payment penalty.  However, you will also not be eligible for a payment bonus.  The penalty/bonus is expected to reach +/-9% in 2022.

Many psychologists will elect to participate in MIPS to benefit from a payment bonus, even if they fall under the low volume threshold.   Psychologists have been exempt from MIPS in the first two years of the program.  In 2019, we will be required to participate in MIPS if we don’t fall under the low volume threshold. Participation in 2019 will make us eligible for a payment penalty or bonus in 2021.

Always keep in mind that CMS may change the low volume threshold and/or any other aspect of the MIPS program on a yearly basis.

In the next blog, I will begin to address the various aspects of MIPS reporting.


Dori Ann Bischmann, PhD

Clinical psychologist

Federal Advocacy Coordinator for APA


APAPO (11/30/2017).  Low-volume threshold expanded in 2018 Quality Payment Program Rule. http://www.apapracticecentral.org/update/2017/11-30/low-volume-threshold.aspx.

Pedulla, D. (2018).  APAPO Government relations staff. Personal communication regarding MIPS.




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