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MACRA Minute – Exclusion vs. Special Status for 2018 MIPS

Helping you put the MIPS pieces together each week!


Difference between Exclusions and Special Statuses for 2018 MIPS

EXCLUSION means you are EXEMPT from participation in MIPS and therefore will not receive a negative or positive payment adjustment. These include:

  • Newly enrolled to Medicare (enrolled during the performance period)
  • Below the low-volume threshold which means:
    • Medicare allowable covered charges less than or equal to $90,000 a year
    • OR 200 or less Medicare part B patients a year
  • Significantly participating in Advanced APMS which means either receiving 25% of Medicare payments or seeing 20% of Medicare patients through an Advanced APM

*Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC): Excluded from MIPS and will not be subject to the MIPS payment adjustments. Eligible clinicians can still voluntarily report MIPS but they will not receive a MIPS payment adjustment.


SPECIAL STATUS does NOT exclude the provider from MIPS. This means the provider is eligible to participate but will have less to do than regular participants:

  • Non-Patient Facing:
    • Individual: less than or equal to 100 patient facing encounters
    • Groups: greater than 75% of NPIs billing under your group’s TIN during a performance period
  • Small Practice: consisting of 15 or fewer eligible clinicians
  • Rural or Health Professional Shortage Areas (HPSA): MIPS eligible clinician, a group, or a virtual group with multiple practices under its TIN (or TINs) with more than 75% of NPIs billing under the individual MIPS eligible clinical or group’s TIN or within a virtual group in a zip code designated as a rural area or HPSA.
  • Hospital-Based: provide 75% or more of services in an Inpatient Hospital (POS 21), On-campus Outpatient Hospital (POS 22), Emergency Room (POS 23) or Off-campus Outpatient Hospital (POS 19).
  • Ambulatory Surgical Center-based: provide 75% or more of services in a POS code 24 (a freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis).

Small Practice, Rural and HPSA: receive double points under the Improvement Activities Performance Category.

Non-patient facing, Hospital-Based, and Ambulatory Surgical Center-based: receive an automatic reweighting of the Promoting Interoperability (previously ACI) performance category.

  • Hospital-Based and Ambulatory Surgical Center-based: If these clinicians exceed the low-volume threshold then they should report on the Quality and Improvement Activities performance categories. If they choose to participate in the Promoting Interoperability category and data is submitted, then they will be scored on this data and the category will be weighted accordingly.


Remember you can check your MIPS Participation Status on the QPP website at:

We encourage providers to re-check their MIPS participation status again in the Fall as it may change.


Contact us to find out more about MediSYS and how we can help you: email: [email protected] or call 205-631-5969 to schedule a free demonstration.