MIPS (Merit-Based Incentive Payment System) is often viewed as a clinical program, but billing teams play a critical role in successful reporting. From coding accuracy to submission tracking, medical billers are key to earning—and protecting—MIPS scores.
This FAQ covers the most common questions billing teams have about MIPS reporting, submission, and compliance.
MIPS is a CMS program that adjusts Medicare payments based on performance in four categories: Quality, Cost, Promoting Interoperability, and Improvement Activities. While clinicians provide the care, billing teams help capture and submit the data that proves it.
Billing accuracy directly impacts:
Quality measure performance
Data completeness
Timely and successful submission
In short, good billing supports good MIPS outcomes.
Not directly, but billers should be part of the conversation. Measure selection is usually led by providers or quality teams, but billers help evaluate:
Coding requirements
Workflow compatibility
Data availability
Being involved early ensures that selected measures align with existing documentation and billing practices.
Incorrect coding is one of the fastest ways to lose points. Each quality measure is tied to specific CPT, HCPCS, or ICD-10 codes. If a service is delivered but not coded properly, the measure may be considered unmet.
Billers should verify:
That billed codes match measure specifications
That modifiers are used correctly
That supporting documentation is present in the chart
Billing codes are used for reimbursement, while QDCs are specific codes used only for MIPS reporting (mainly when reporting via Medicare Part B claims).
Billers reporting through the claims method must know how to:
Identify eligible encounters
Add the correct QDCs to each claim
Ensure they’re not stripped out during claims processing
This is especially important for small practices using the claims-based submission method.
Data completeness means reporting on a certain percentage of eligible patients for each measure—usually at least 70%.
Billers contribute by:
Tracking which claims are tied to MIPS measures
Flagging missing codes or incomplete encounters
Running regular internal audits to identify gaps
Depending on the practice’s setup, helpful tools may include:
EHR dashboards for real-time quality tracking
Registry portals with data validation features
Internal billing reports filtered by MIPS-related CPT codes
Coding crosswalks that map each measure to billable services
These tools help ensure alignment between clinical documentation and billing data.
CMS may audit MIPS submissions. Billers should help maintain:
Copies of submitted data and confirmation receipts
Coding guidelines or crosswalks used during reporting
Internal performance reports
Supporting documentation for each claimed measure
Records should be retained for at least six years.
Missing the submission window (usually by March 31 of the following year) results in an automatic negative payment adjustment. If that happens, there's no appeal process based on timing alone.
Billers should monitor submission progress and work closely with whoever is managing final uploads—whether it’s the registry, the EHR vendor, or an internal quality team.
Medical billing staff are essential partners in the MIPS reporting process. By understanding how billing data affects quality scores, working closely with providers, and maintaining clean records, billing teams can help protect the practice from penalties and improve financial performance under MIPS.