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Centers for Medicare & Medicaid Services Quality Payment Program. Small Practices Newsletter
Quality Payment Program Small Practices Newsletter: March 2025

The Quality Payment Program (QPP) Small Practices Newsletter is a monthly resource that provides small practices (15 or fewer clinicians) with program updates, upcoming QPP milestones, and resources to support their continued participation and success in QPP. 

Please share this newsletter with your fellow clinicians and practice staff and encourage them to sign up [ https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12879%2F&utm_source=newsletter&utm_medium=email&utm_id=newsletter_january2024&utm_content=smallpracsignup ] to receive this monthly resource.

*At-a-Glance: Required and Recommended Activities for Successful Participation in QPP *

Each month, we share required and recommended activities for small practices to support their successful participation in QPP. The activities follow a rolling quarter approach, letting you see activities for the previous month, the current month, and the following month.

Small_Practice_Timeline

*In This Issue:                                                                                 *

*Hot Topics: What You Need to Know*


* Data Submission Window for 2024 Performance Year Closes March 31, 2025 [ #link_1 ]
* Reminder: 2025 MIPS Resources Now Available [ #link_2 ]
* 2025 MIPS Quality Benchmarks Released [ #link_3 ]
* MIPS Automatic Extreme and Uncontrollable Circumstances (EUC) Policy Applied to MIPS Eligible Clinicians Following California Wildfires for 2024 and 2025 Participation [ #link_4 ]
* Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults eCQM- Measure Clarification [ #link_5 ]
* Relevant Resources [ #link_6 ]
* We Want to Hear From You [ #link_7 ]

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Data Submission Window for 2024 Performance Year Closes March 31, 2025

The data submission window for the 2024 performance year is now open. You can submit data for the 2024 performance year until the submission window closes at *8 p.m. ET on* *March 31, 2025*.

*How to Submit and Review Your 2024 Merit-based Incentive Payment System (MIPS) Data*

Follow the steps outlined below to submit data:


* Go to the QPP sign-in page [ https://qpp.cms.gov/login ].
* Sign in using your QPP access credentials.
* Submit your data for the 2024 performance year or review the data reported on your behalf by a third party. *(You can’t correct errors with your data after the submission period, so it’s important to ensure the data submitted on your behalf is accurate.)*

Submission resources are available now on the QPP Resource Library [ https://qpp.cms.gov/resources/resource-library ].

*Highlighted Submission Resources:*


* 2024 JSON Template and Instructions (ZIP, 856KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3111/2024-JSON-Templates-and-Instructions.zip ]: This resource provides instructions for using the associated QPP JSON templates to submit the quality data you’ve collected for MIPS clinical quality measures.
* 2024 Traditional MIPS Data Submission User Guide (PDF, 3MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3084/2024-Traditional-MIPS-Data-Submission-Guide.pdf ]: This resource provides information and screenshots for submitting your traditional MIPS data.
* 2024 MVP Data Submission User Guide (PDF, 4MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3085/2024-MVP-Data-Submission-Guide.pdf ]: This resource provides information and screenshots for submitting your MIPS Value Pathways (MVPs) data.
* 2024 APP Data Submission User Guide (PDF, 3MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3086/2024-APP-Data-Submission-Guide.pdf ]: This resource provides information and screenshots for submitting your Alternative Payment Model (APM) Performance Pathway (APP) data.

*How to Sign in to the QPP Data Submission System*

To sign in and submit data, clinicians will need a Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) account and a QPP role. For help enrolling with HARP, please refer to “Step 1. Register for a HARP Account” in the QPP Access User Guide (ZIP, 4MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2955/QPP-Access-User-Guide.zip ]. For help obtaining a QPP role, please refer to “Step 2a. Connect to an Organization” in the QPP Access User Guide (ZIP, 4MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2955/QPP-Access-User-Guide.zip ].

The Centers for Medicare & Medicaid Services (CMS) encourages all users with an existing HARP account to sign in to the QPP website [ https://qpp.cms.gov/login ] now to ensure they don’t lose access.

*Note: *Clinicians who are unsure about their eligibility to participate in MIPS for the 2024 performance year can check their final eligibility status using the QPP Participation Status Tool [ https://qpp.cms.gov/participation-lookup ]. Clinicians and groups that are opt-in eligible will need to make an election to opt in or voluntarily report before they can submit data. (No election is required for opt-in eligible clinicians and groups that don’t want to participate in MIPS.) Review the 2024 MIPS Eligibility & Participation Quick Start Guide (PDF, 1MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2623/2024MIPSEligibandParticGuide.pdf ] for more information about eligibility.

*Reminder: Preliminary Scoring No Longer Available During Submission*

As a reminder, CMS eliminated the preliminary score and preliminary category-level scores from submission. We’ll release 2024 MIPS final scores in mid-June 2025.

*Submit Your Data Early*

We encourage you to submit your 2024 MIPS performance period data early during the submission period. Early submission will allow you plenty of time for QPP Service Center assistance if needed.

*Upcoming QPP Service Center Hold Times*

The QPP Service Center is projecting an increase in volume between now and the close of the data submission window for the 2024 performance year on March 31, 2025, which could result in longer wait times.

CMS recommends the following to minimize wait times and ensure successful 2024 data submission:

You can schedule a call with a member of the QPP Service Center team by clicking on Schedule a Call.

You can also submit a ticket for support by clicking on Request Support.

Live Chat: CCSQ Support Central Chat and Resource Line (CARL)

The Support Central Chat feature, CARL, is another option to use for assistance. To contact the Service Center via chat, go to the CCSQ Support Central [ https://cmsqualitysupport.servicenowservices.com/ccsq_support_central ] page and click on the “Live Chat” icon in the lower right area:

Live Chat Icon

*Use One Method to Report Issues *

Due to the anticipated increase in volume at the QPP Service Center and to minimize a backlog, please use only *_one_* method of reporting for the same issue (email, phone, or CCSQ Support Central).

Note: Cases are processed in the order in which they’re received, regardless of how the QPP Service Center was contacted. Please allow time for processing.

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Reminder: 2025 MIPS Resources Now Available

The new 2025 MIPS resources are now available on the QPP Resource Library [ https://qpp.cms.gov/resources/resource-library ].


* 2025 MIPS Quick Start Guide for Small Practices (PDF, 3MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3115/2025-MIPS-Quick-Start-Guide-for-Small-Practices.pdf ]
* This consolidated guide provides a high-level overview of MIPS requirements for small practices, identifies key policy updates for 2025, and includes a printable checklist for submitting 2025 data.

* 2025 Part B Claims Reporting Quick Start Guide (PDF, 3MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3118/2025-Part-B-Claims-Measure-Reporting-Quick-Start-Guide.pdf ]
* 2025 Promoting Interoperability Quick Start Guide (PDF, 849KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3112/2025-Promoting-Interoperability-Quick-Start-Guide.pdf ]
* 2025 Quality Quick Start Guide (PDF, 2MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3116/2025-Quality-Quick-Start-Guide.pdf ]
* 2025 Finalized MIPS Value Pathways Guide (PDF, 2MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3058/2025-Finalized-MIPS-Value-Pathways-Guide.pdf ]

*2025 MIPS Quality Measure Specifications*

The following documents, which provide comprehensive descriptions and details on 2025 quality measures, are available:


* 2025 Acute Cardiovascular-Related Admission Rates for Patients with Heart Failure Measure (ZIP, 1MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3142/2025-MIPS-Heart-Failure-Measure-Specification.zip ]
* 2025 All-Cause, Unplanned Hospital-Wide Readmission Measure (ZIP, 854KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3119/MIPS_Hospital-Wide-Readmission_2025.zip ] 
* 2025 All-Cause Unplanned Admissions for Multiple Chronic Conditions Measure (ZIP, 5MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3143/2025-MIPS-MCC-Measure-Specification.zip ]
* 2025 Cross-Cutting Quality Measures (PDF, 267KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3126/2025-Cross-Cutting-Quality-Measures.pdf ]
* 2025 Hip Arthroplasty and Knee Arthroplasty (THA/TKA) Complications Measure (ZIP, 556KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3120/MIPS_THA_TKA_Complications_2025.zip ]
* 2025 Medicare Part B Claims Measure Specifications and Supporting Documents (ZIP, 29MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3094/2025-Part-B-Claims-Measure-Specifications-and-Supporting-Documents.zip ]
* 2025 MIPS Quality Measures List (XLS, 804KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3125/2025-MIPS-Quality-Measures-List.xlsx ]
* 2025 MIPS Clinical Quality Measure Specifications and Supporting Documents (ZIP, 68MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3093/2025-MIPS-CQM-Specifications-and-Supporting-Documents.zip ]
* 2025 MVP Quality Measure Specifications for Quality IDs 112, 113, and 128 (ZIP, 2MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3127/2025-MIPS-Value-Pathways-Quality-Measure-Specifications.zip ]
* 2025 Qualified Clinical Data Registry (QCDR) Measure Specifications (XLS, 680KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3108/2025_QCDR_Measure_Specifications_PUB.xlsx ]

As a reminder, the 2025 Electronic Clinical Quality Measure Specifications [ https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ec-ecqms&globalyearfilter=&global_measure_group=eCQMs ] have been available on the Electronic Clinical Quality Improvement (eCQI) website since spring 2024.

The 2025 QPP Final Rule Webinar slide deck [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3089/2025QPPFinalRuleSlides.pdf ] and recording [ https://youtu.be/IFNnL3DOUQ0 ] are available on the QPP Webinar Library [ https://qpp.cms.gov/resources/webinars ].

*Additional 2025 MIPS Measures and Activities Resources*

The following resources related to other MIPS performance categories are now also available:


* 2025 Promoting Interoperability Measure Specifications (ZIP, 4MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3122/2025-MIPS-Promoting-Interoperability-Measure-Specifications.zip ]
* 2025 Improvement Activities Inventory and Activity Descriptions (ZIP, 831KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3131/2025-Improvement-Activities-Inventory.zip ]
* 2025 MIPS Summary of Cost Measures (PDF, 340KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3129/2025-mips-summary-cost-measures.pdf ]
* 2025 MIPS Cost Measure Information Forms (ZIP, 19MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3128/2025-cost-measure-information-forms.zip ]
* 2025 MIPS Cost Measure Codes Lists (ZIP, 21KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3130/2025-cost-measure-codes-lists.zip ]

The Explore Measures & Activities Tool [ https://qpp.cms.gov/mips/explore-measures?tab=qualityMeasures&py=2025 ] on the QPP website can help you get familiar with the available measures and activities for each performance category under traditional MIPS. Explore Measures & Activities [ https://qpp.cms.gov/mips/explore-measures?tab=qualityMeasures&py=2025 ] has been updated to include measures and activities for the 2025 performance year, with links to the individual specifications.

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2025 MIPS Quality Benchmarks Released

The 2025 historical benchmarks for quality measures [ https://qpp.cms.gov/benchmarks#benchmarks-2025 ] are now available on the Benchmarks webpage [ https://qpp.cms.gov/benchmarks ] of the QPP website. Benchmarks are the point of comparison we use to score the measures you submit. Your performance on each measure is compared to its benchmark to determine how many points the measure can earn.

From the Benchmarks webpage [ https://qpp.cms.gov/benchmarks ], you can download:


* 2025 Quality Benchmarks Version History (PDF, 218KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3160/2025-Quality-Benchmarks-Version-History.pdf ]__
* 2025 Quality Benchmarks User Guide with Scoring Examples (PDF, 964KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3162/2025-Quality-Benchmarks-User-Guide.pdf ]__
* 2025 Multiple Performance Rate Measures File (XLSX, 72KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3161/2025-Multiple-Performance-Rate-Measures.xlsx ]

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MIPS Automatic Extreme and Uncontrollable Circumstances (EUC) Policy Applied to MIPS Eligible Clinicians Following California Wildfires for 2024 and 2025 Participation

In response to the California wildfires, as identified by both the Department of Health and Human Services (HHS) Public Health Emergency (PHE) declaration (California [ https://aspr.hhs.gov/legal/PHE/Pages/CA-Wildfires-Jan2025.aspx ]) and Federal Emergency Management Agency (FEMA) disaster declaration (DR-4856-CA [ https://www.fema.gov/disaster/4856/designated-areas ]), CMS has determined that the MIPS automatic EUC policy will apply to MIPS eligible clinicians in designated affected counties of California for both the 2024 and 2025 performance periods.

MIPS eligible clinicians in these areas will be automatically identified and have all 4 performance categories reweighted to 0% during the data submission period for the 2024 performance period (January 2, 2025 to March 31, 2025) and the 2025 performance period (January 2, 2026, to March 31, 2026). This will result in a score equal to the performance threshold, and they’ll receive a neutral payment adjustment for the 2026 and 2027 MIPS payment years.

However, if MIPS eligible clinicians in these areas submit data on 2 or more performance categories for either or both performance years, they’ll be scored on those performance categories and receive a payment adjustment based on their MIPS final score(s).

NOTE: The MIPS automatic EUC policy doesn’t apply to MIPS eligible clinicians participating in MIPS as a group, subgroup, virtual group, or APM Entity. However, groups, virtual groups, and APM Entities can request reweighting through the EUC Exception application. Subgroups will inherit any reweighting approved for their affiliated group; they can’t request reweighting independent of their affiliated group’s status.

*For More Information*

Please reference the MIPS EUC Exception section on the QPP Exception Applications webpage [ https://qpp.cms.gov/mips/exception-applications ], the 2024 MIPS Automatic EUC Policy Fact Sheet (PDF, 401KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2840/2024-MIPS-Automatic-EUC-Policy.pdf ], and the 2025 MIPS Automatic EUC Policy Fact Sheet (PDF, 334KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3164/2025-MIPS-Automatic-EUC-Policy.pdf ].

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Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults eCQM- Measure Clarification

CMS is providing clarification regarding the reporting requirements for the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults electronic clinical quality measure (eCQM) beginning with the 2025 performance period.

Hospitals and clinicians who choose to report this eCQM may use any vendor’s software that meets the necessary requirements to generate the standardized data elements required to calculate the measure, consistent with the measure’s specifications. Hospitals and clinicians aren’t required to use the Alara Imaging software for CMS measure compliance. Any software vendor capable of calculating and reporting this eCQM in accordance with the measure’s specifications, including transforming radiology data into a format compatible with eCQM reporting, may report this measure on behalf of hospitals and clinicians. Hospitals and clinicians aren’t required to demonstrate to CMS that the software they or their vendors use can generate and transform the radiology data into the necessary format. However, nothing would prevent a hospital or clinician seeking assurance about the ability of specific software to perform these tasks from requesting that information from a vendor.

As with all eCQMs, CMS will monitor measure results to ensure that all reported data for the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults eCQM is both reliable and valid. This may include analyzing data to identify outliers and common characteristics of outlier submissions.

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Relevant Resources

2025 MIPS Quick Start Guide for Small Practices (PDF, 3MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3115/2025-MIPS-Quick-Start-Guide-for-Small-Practices.pdf ]

2025 Part B Claims Reporting Quick Start Guide (PDF, 3MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3118/2025-Part-B-Claims-Measure-Reporting-Quick-Start-Guide.pdf ]

2025 Promoting Interoperability Quick Start Guide (PDF, 849KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3112/2025-Promoting-Interoperability-Quick-Start-Guide.pdf ]

How to Participate as a Group in MIPS (VIDEO) [ https://www.youtube.com/watch?v=dRNd-YMgbHc&list=LL&index=6&t=90s ]

Do I Need to Participate in MIPS? How to Check Eligibility Status (VIDEO) [ https://www.youtube.com/watch?v=rHoH4hJaetI ]

Small Practices FAQs on the Small Practices page of the QPP website [ https://qpp.cms.gov/resources/small-practices#:~:text=FAQs%20(PDF%2C%20461KB)-,FAQs,-Am%20I%20eligible ]

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We Want to Hear From You

Share your feedback <QPPUserResearch@cms.hhs.gov> on what you like most about the Small Practices Newsletter, what can be improved, and/or what topics you would like to see addressed. Please include “Small Practices Newsletter” in the email subject line.

Quality Payment Program [ https://qpp.cms.gov/resources/help-and-support ]


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