Quality Payment Program (QPP)/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

Forms and Documents

Document Name	Status
Form Appendix A1 CY 2025 Performance Period/2027 MIPS Payment Year Form and Instruction	New
Form Appendix A1 CY 2024 Performance Period/2026 MIPS Payment Year Burden Summary Form and Instruction	Removed
CMS-10621_Supporting_Statement_B_508_(CMS-1807-P version 1).docx Supporting Statement B	2024-09-17
CMS-10621_Supporting_Statement_A_508_(CMS-1807-P version 2).docx Supporting Statement A	2024-09-17

IC Document Collections

IC ID	Document Title	Status
271014	CY 2025 Performance Period/2027 MIPS Payment Year Form and Instruction	New
250664	CY 2024 Performance Period/2026 MIPS Payment Year Burden Summary Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1314	ICR Reference No: 202409-0938-018
Status: Received in OIRA	Previous ICR Reference No: 202311-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Payment Program (QPP)/Merit-Based Incentive Payment System (MIPS) (CMS-10621)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/19/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2027
Responses	136,053	191,225
Time Burden (Hours)	649,776	728,142
Cost Burden (Dollars)	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV33	Proposed rulemaking	89 FR 61596	07/31/2024

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 61596	07/31/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
CY 2024 Performance Period/2026 MIPS Payment Year Burden Summary	Appendix J1, Appendix A1, Appendix B1, Appendix D1, Appendix E, Appendix F, Appendix G1, Appendix H1, Appendix K1, Appendix L, Appendix C1, Appendix I1	2024 MIPS QCDR and Registry Self-nomination User Guide ,   2024 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) ,   2024 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) ,   2024 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option ,   Measures under Consideration 2023 Data Template for Candidate Measures ,   2023 Peer Reviewed Journal Article Requirement Template ,   Improvement Activities Performance Category, 2024 Call for Activities Submission Form ,   2023 MIPS Promoting Interoperability Hardship Exception Application Guide ,   2023 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide ,   2024 MVP Candidates: Instructions and Template ,   2023 Partial QP Election Form ,   2023 MVP Registration Form
CY 2025 Performance Period/2027 MIPS Payment Year	Appendix A1, Appendix B, Appendix C, Appendix D, Appendix F1, Appendix H1, Appendix I1, Appendix J, Appendix L, Appendix E1, Appendix G, Appendix K	2025 MIPS QCDR and Registry Self-nomination User Guide ,   2024 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) ,   2024 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission ,   2024 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option ,   Measures under Consideration 2024 Data Template for Candidate Measures ,   2024 Peer Reviewed Journal Article Requirement Template ,   Improvement Activities Performance Category, 2024 Call for Activities Submission Form ,   2024 MIPS Promoting Interoperability Hardship Exception Application Guide ,   2024 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide ,   2024 MVP Candidates: Instructions and Template ,   2023 Partial QP Election Form (for submission in CY 2024) ,   2024 MVP Registration Form

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	136,053	191,225	0	136,053	-191,225	0
Annual Time Burden (Hours)	649,776	728,142	0	649,776	-728,142	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The changes in this CY 2025 collection of information request are associated with our July 31, 2024 (89 FR 61596) proposed rule (CMS-1807-P, RIN 0938–AV33). Overall, this iteration proposes to decrease the current estimates by 55,172 responses (from 191,225 to 136,053 responses) and 78,366 hours (from 728,142 to 649,776 hours).

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Annual Cost to Federal Government: $384

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/19/2024

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