Search form

Reg-ent℠ MIPS 2020 Reporting

Reg-ent℠ MIPS 2020 Reporting

Reg-ent is the MIPS reporting tool of choice for otolaryngologists. As a Qualified Clinical Data Registry (QCDR), Reg-ent accommodates reporting for all required MIPS 2020 performance categories, including Quality, Promoting Interoperability (PI), and Improvement Activities (IA). Reg-ent staff at AAO-HNSF and FIGmd (the registry's technical vendor partner) will work closely with your practice through the process of Quality measures mapping and measures selection, PI, and IA data entry and attestations, and ultimately the submission to CMS through the Reg-ent Pegasus Dashboard. Reg-ent supports both group and individual clinician reporting methods.

MIPS Participation and Eligibility:

CMS requires all MIPS eligible clinician types to report MIPS if they meet the requirements to report for the current performance year. Click here for more information regarding eligible provider types.

Group vs. Individual Reporting

Practices and/or providers can report MIPS one of two ways: as a Group or as an Individual. When reviewing your options to report, please be mindful of the requirements to report as a group or individual.

  • Practices or TINs with 2 or more providers can report as a group, however, all eligible clinician types are included in your submission. These include mid-level providers, audiologists, speech-language pathologists, etc.
  • If the practice chooses to report individually, the submission requirements only call for individuals who meet all the low-volume threshold requirements at the practice and clinician level.

The low-volume threshold requirements (LVT) are applied at the clinician and practice level. The LVT includes 3 aspects of covered professional services:

  • Allowed charges
  • Number of beneficiaries who receive services
  • Number of services provided

The LVT influences the provider’s or practice’s eligibility status during the determination periods. CMS updates eligibility data at multiple points throughout the year in order to help you plan your program participation. These updates are based on past and current Medicare Part B Claims and PECOS data. For the 2020 performance year, the initial snapshot was provided in December 2019 and is scheduled to be finalized in November 2020. The CMS Participation Lookup Tool allows providers to regularly check their reporting status by entering their NPI number in the Lookup textbox.

You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments, you:

  • Bill more than $90,000 for Part B covered professional services, and
  • See more than 200 Part B patients, and;
  • Provide 200 or more covered professional services to Part B patients.

It is important to find out your eligibility status for the reporting year. You can verify this information on the CMS QPP Website, please click here to check your eligibility.

MIPS Scoring:

The MIPS Score is based on performance in all four categories:

  • Quality (45%)
  • Improvement Activities (15%)
  • Promoting Interoperability (25%)
  • Cost (15%) *Cost is calculated separately by CMS*

The minimum amount of points needed to avoid the negative -9% payment adjustment is 45 points.
Those who score more than 85 points will be eligible for an additional positive payment adjustment (up to 9%) and may share in the pool of $500 million of funding available for the year.

Quality Measure Bonus Points:

Bonus points can be earned by reporting more than one high priority and outcome measure:

  • For every additional outcome measure reported, 2 bonus points can be applied
  • For every additional high priory measure reported, 1 bonus point can be applied.
  • The maximum amount for bonus points under quality is 6.

Small Practice, Rural, and Health Professional Shortage Areas Exceptions and Bonuses:

For 2020, CMS will add 6 measure points to the numerator of small practice's Quality Performance Category score as long as the small practice submits data to MIPS on at least 1 quality measure. The addition of the 6 measure bonus points generally represents 10% of the quality performance category score for small practices. If a small practice is unable to meet the measure or meet the "data completeness" the practice will still receive 3 points for that measure. Clinicians located in federally defined rural or Health Professional Shortage Areas (HPSA) will receive the same scoring logic and bonus point opportunity as small practices.

Reg-ent 2020 Quality Measures:

Reg-ent's 2020 Qualified Clinical Data Registry (QCDR) designation includes approval of 17 otolaryngology-specific measures developed by and for AAO-HNS members. Reg-ent participants who have direct EHR integration with Reg-ent may use the QCDR measures for MIPS 2020 reporting. Reg-ent Web Tool participants do not have access to the QCDR measures but are able to use QPP measures for MIPS.

To view the full list of quality measures available through the Reg-ent Registry, please click here!

Reg-ent MIPS 2020 Promoting Interoperability (PI) Reporting:

CMS has changed the name of the Advancing Care Information (ACI) category to the Promoting Interoperability (PI) category. To earn full credit in this performance category an individual clinician or the practice must attest that they have complied with the measure requirements within 90 continuous days or more during 2020. Please note, only practices that have an EHR that is certified to the 2015 edition will be able to report the PI category. Paper-based practices will be unable to report the PI category. To identify your EHR edition, click here.  To view all of the PI measures, please click here.

  • In addition to submitting measures, clinicians must submit a “yes” to:
    • The Prevention of Information Blocking Attestation,
    • The ONC Direct Review Attestation, and;
    • The security risk analysis measure.

The PI Hardship Exception Application is available for a practice that may qualify. To see if you or your practice is eligible, please click here.

Reg-ent MIPS 2020 Improvement Activities (IA) Reporting:

To earn full credit in this performance category, participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2020):

  • 2 high-weighted activities
  • 1 high-weighted activity and 2 medium-weighted activities
  • 4 medium-weighted activities

High-weighted activities receive 20 points and medium-weighted activities receive 10 points.
Small practices receive double points for reporting IA measures. A small practice can earn all the available points in the IA category by reporting two medium-weighted activities OR one high weighted activity. Clinicians located in federally defined rural or Health Professional Shortage Areas (HPSA) will receive the same scoring logic and bonus point opportunity as small practices.


The Reg-ent registry contains all Improvement Activities offered by CMS for MIPS 2020 reporting and Reg-ent participants can review assigned points for each IA, make selections, review scores, and then submit to CMS through the Reg-ent MIPS dashboard.