Submitting accurate and complete data under the Merit-Based Incentive Payment System (MIPS) is essential for avoiding penalties and earning potential incentives. This checklist outlines the key steps billing and administrative staff should follow to ensure a successful MIPS submission. Use it as a guide to stay organized, meet deadlines, and maintain compliance with CMS requirements.
Verify Provider Eligibility
Confirm that your provider(s) meet the low-volume threshold and are required or voluntarily choosing to report.
Determine Submission Type
Choose the correct submission method:
Qualified Registry
Qualified Clinical Data Registry (QCDR)
Electronic Health Record (EHR)
Medicare Part B Claims (for small practices)
CMS Web Interface (if applicable)
Review Performance Categories
Understand the current category weights and any changes to reporting requirements:
Quality
Promoting Interoperability
Improvement Activities
Cost (calculated by CMS automatically)
Select Measures
Choose six Quality measures (including one outcome or high-priority measure) that best align with your provider’s specialty and workflow.
Gather Required Data
Confirm you have all supporting documentation for Quality, Promoting Interoperability, and Improvement Activities. Ensure data meets CMS’s completeness thresholds.
Monitor Performance Regularly
Use your EHR or registry to track progress throughout the year and address any data gaps early.
Audit Internal Data
Periodically check for consistency between provider documentation and submitted codes.
Maintain Communication with Providers
Ensure that documentation is being completed accurately and timely for each selected measure.
Verify Measure Codes and Eligibility Criteria
Double-check that all reported codes are current and meet CMS definitions.
Confirm Data Completeness
Validate that each Quality measure is reported on at least 70% of eligible patients (or the current CMS requirement for the performance year).
Review Promoting Interoperability Requirements
Ensure the EHR is certified and that all required objectives and measures are met, including security risk assessments.
Document Improvement Activities
Keep records of all activities claimed, including the activity description, duration, and participation details.
Use CMS Submission Tools or Registry Portals
Make sure data has been correctly uploaded and reviewed before finalizing the submission.
Download Submission Receipts
Save proof of submission, including confirmation emails and screenshots from registries or CMS systems.
Retain All Supporting Documentation
Maintain records for six years in case of audit.
Review CMS Feedback Reports
Once available, analyze performance scores and identify areas for improvement.
Plan for Next Performance Year
Use insights from your current submission to adjust measure selection, workflows, and training needs moving forward.
Following a structured checklist helps eliminate errors, reduce reporting stress, and protect your organization from financial risk. Keep this document accessible throughout the year to ensure all MIPS reporting steps are completed accurately and on time.