If you are a clinician working in healthcare, you’ve probably heard about MIPS reporting requirements. But not everyone has to participate. Four main CMS MIPS exceptions might apply to you.
Understanding these CMS MIPS exceptions can save you time and help you focus on caring for your patients. This blog explains each exception in simple terms so you can figure out if you qualify.
Understanding CMS MIPS Exceptions
Clinicians can avoid MIPS reporting services in several ways. You may be exempt if you are not considered MIPS eligible or if your Medicare volume falls below the required thresholds. Newly enrolled Medicare providers may also qualify for an exemption. Participation in an Advanced APM can remove the reporting requirement as well. Each option follows specific CMS guidelines that should be reviewed carefully.
Not Qualifying as a MIPS Eligible Clinician
The first of the CMS MIPS exceptions applies if you don’t fall into one of the clinician types that CMS has identified for program participation.
CMS has created a list of more than a dozen clinician types that must participate in MIPS healthcare program. The list spans many healthcare roles, covering doctors, advanced practice clinicians, therapists, and mental health professionals.
Several other healthcare professionals are included on this list as well.
Here’s something important to know. This list gets updated every year. So if you are not eligible this year, you might be next year. Always check the latest guidelines on the CMS website to see where you stand with CMS MIPS exceptions.
Low Volume Threshold Exemption
You can be MIPS eligible and still not have to participate. If your Medicare billing volume is small, you may be exempt.
These numbers can change from year to year, so you need to check the current thresholds for each performance year. The low-volume threshold is CMS’s way of not burdening smaller practices with MVPs reporting requirements.
If your practice is just below these thresholds, you might want to track your numbers throughout the year. This way, you’ll know if you are staying within the CMS MIPS exceptions or if you need to prepare for reporting.
New Medicare Enrollment Exemption
The third of the CMS MIPS exceptions applies to clinicians who just enrolled in Medicare.
Each MIPS performance year starts on January 1st. If you enroll in Medicare after that date, you don’t have to participate in MIPS healthcare reporting until the next performance year.
For example, if you enrolled on January 15th, you’d get a pass for that entire year. You wouldn’t need to worry about reporting until the following January 1st.
This exception makes sense because it gives new Medicare providers time to get established before taking on additional reporting requirements with CMS MIPS exceptions 2025.
Advanced Alternative Payment Model Participation
The last of the CMS MIPS exceptions involves Alternative Payment Models, but there’s a catch. It has to be an advanced APM.
What’s the difference? CMS designates some payment models as Advanced APMs when they meet required criteria. These models focus on value-based care and involve taking on more financial risk in exchange for potential rewards.
To be exempt through this path, you need to achieve what’s called Qualifying Participant status. CMS determines this status based on how much of your practice participates in the Advanced APM.
Here’s an important point. If you are in an APM but don’t meet the requirements for QP status, you are not fully exempt. You’ll still need to do reporting, but you’ll get some favorable treatment in certain scoring categories.
The Advanced APM route can be complex, so check out CMS’s overview materials if you think this exception might apply to you.
Benefits of Understanding Your Exemption Status
Understanding CMS MIPS exceptions 2025 is important for several reasons.
It saves time and resources. Reporting takes effort. If you qualify for an exception, you can use that time for patient care instead.
It reduces stress. Not having to worry about meeting MIPS requirements and potential payment adjustments can give you peace of mind.
It helps with planning. Knowing your status helps you plan your practice operations and budget for the year ahead with clear information about CMS MIPS exceptions.
Annual Review of Your MIPS Status
Your MIPS healthcare eligibility can change from year to year.
Maybe you had 180 Medicare patients last year but picked up new patients this year. Or perhaps you were newly enrolled last year but now you’ve been in Medicare for over a year. These changes mean you might lose your exemption status.
That’s why you should check your MIPS eligibility annually. Don’t assume that because you were exempt last year, you’ll be exempt this year under CMS MIPS exceptions.
The thresholds, requirements, and eligible clinician types can all shift from one performance year to the next.
Changes Coming to Healthcare Programs
CMS has announced plans to phase out traditional MIPS over the next several years. they are moving toward a new program called MIPS Value Pathways, which will be more focused on specific specialties.
What does this mean for you? The CMS MIPS exceptions might change too. The eligibility requirements, thresholds, and exemption criteria could all shift as the new program rolls out.
Stay informed about these changes by regularly checking CMS updates and guidance documents. What qualifies as CMS MIPS exceptions today might be different in future years.
How Prime Well Med Solutions Can Help
If you find out you don’t qualify for any of the CMS MIPS exceptions and need to report, don’t worry. Help is available.
Prime Well Med Solutions offers comprehensive support for clinicians dealing with MIPS reporting requirements. Here’s what makes Prime Well Med Solutions different from other vendors.
- Each client gets a clinical quality advisor who helps with both technical and clinical needs. You are not just getting software. You are getting a person who understands your challenges.
- Prime Well Med Solutions helps you work through technical and clinical issues to improve your performance measure.
- Your advisor keeps you on track for submission deadlines so you never miss critical dates.
- Prime Well Med Solutions helps you choose and set up measures that make sense for your specific situation.
- You can call your advisor anytime with questions or concerns. There’s no limit on support hours.
Many clients say the biggest difference between Prime Well Med Solutions and other vendors is the level of support they receive. If you are currently using an EHR vendor for reporting, you’ll notice a significant difference in the attention and help you receive from us.
Determining Your Exemption Eligibility
Understanding CMS MIPS exceptions is the first step in figuring out your reporting requirements. Whether you qualify for an exception through low volume, new enrollment, clinician type, or Advanced APM participation.
Remember to check your eligibility every year since the rules and thresholds for CMS MIPS exceptions can change. And if you don’t qualify for an exemption, know that support is available through Prime Well Med Solutions to make MIPS reporting easier and less stressful.
Take the time now to review your situation and determine if any of the CMS MIPS exceptions apply to you. Understanding where you stand with requirements will help you manage your practice more effectively.
Check the CMS website regularly for updates on CMS MIPS exceptions for 2026 and future years to stay informed about any changes that might affect your practice.
You May Need to Read:
Understanding the 2026 Medicare Physician Updates for Your Practice
What Are eCQMs and How Do They Compare to Other Quality Measures
5 MIPS Confusing Parts That Trip Up Healthcare Providers And How to Fix Them
