MIPS CAP and Registry Updates

September 22, 2022

Each year APS works with qualified registries and our clients to report MIPS data to CMS. For 2021, many of our clients utilized the Extreme and Uncontrollable Circumstances (EUC) exemption that was offered by CMS due to the ongoing COVID-19 pandemic. Of those that reported, the averages for total points and total cost adjustment are listed below.

CMS’ MIPS program continues to undergo update after update – sometimes mid-year. APS provides education and resources to help our clients make the most of what is available. For example, in 2021 we helped several clients submit data through the CAP, utilizing their QCDR registry in addition to the traditional MIPS measures offered by CMS to increase their scoring potential. 

Overall data for APS clients in performance year 2021:

Method of Submission Avg Total Points Avg Total Adjustment
Qualified Registry 82.8 0.29%
CAP 97.5 1.9%


There are several criteria and program changes for 2022 to keep in mind:

•    The performance threshold increases from 60 points to 75 points
•    The exceptional performance threshold increases from 85 points to 89 points
•    Instead of category weighting of 85% Quality + 15% Improvement Activities applying to all practices, it will only apply to Large Practices (over 15 clinicians as designated by CMS) in 2022; Small Practices (15 and fewer clinicians as designated by CMS) will receive category weighting of 50% Quality + 50% Improvement Activities
•    The formula for determining complex patient bonuses is expected to change but CMS hasn’t defined what the change is; it’s generally thought that it will result in fewer practices receiving the bonus but that remains to be seen with the 2022 results
•    Facility-based scoring measurement was supposed to ‘come back’ in 2022 after being revoked in 2021 due to the Public Health Emergency (PHE); CMS recently revoked it for 2022 as well, which is disappointing as a number of our clients benefitted from it in the past

For the 2022 performance year, the EUC is still available as always, but as yet is not being automatically applied as it was in previous years (The current PHE related to COVID-19, which triggered an automatic EUC for several groups in the past, is set to expire in October 2022).