What Are the Most Overlooked Steps in MIPS and MVP Documentation?

MIPS and MVP documentation requirements can feel overwhelming, especially when you’re balancing patient care with administrative tasks. Many providers lose out on incentives or face penalties not because they lack clinical expertise, but because they miss key documentation steps that affect their final scores and reimbursement rates.

The mistakes are more common than you’d think, but most of them are preventable with the right systems and planning.

Key Takeaways

Missing documentation deadlines can result in automatic penalties or lost incentive opportunities.
Incomplete or inaccurate data entry leads to lower MIPS scores and failed submissions.
Skipping performance category reviews means missing chances to optimize your scores.
Not verifying measure eligibility before reporting can waste time and reduce your final score.
Ignoring feedback reports prevents you from making improvements in future reporting cycles.

Choosing Measures Without Verifying Eligibility

One of the first mistakes happens before data collection even starts. Providers pick measures without confirming eligibility. Some measures have specific patient volume requirements or specialty restrictions, and reporting on a measure you don’t qualify for can result in CMS rejecting it entirely.

Check the specifications before committing. Make sure your patient population matches the criteria and that you can meet the data completeness threshold.

Failing to Meet Data Completeness Thresholds

Data completeness is a requirement that trips up many providers. CMS requires you to meet a minimum data completeness percentage for each measure, and falling short means your score takes a hit. You can’t report on a handful of patients and call it done.

Common completeness mistakes include:

Waiting until the last quarter to start gathering information
Assuming you’re collecting enough data without tracking progress
Not using automated systems to monitor percentages in real time

Tracking your progress regularly helps you catch gaps early. Set up reminders or use automated systems to see how close you are to the required percentage. If you’re behind, you still have time to adjust before the submission deadline.

Missing Critical Submission Deadlines

Deadlines in MIPS reporting are strict. Missing them can result in penalties or being scored as if you didn’t participate at all. Many providers miss deadlines because they underestimate how long data preparation takes.

Rushing at the last minute increases errors. You might submit incomplete data or forget required documentation.

Create a reporting timeline at the start of the year. Break the process into smaller tasks with individual deadlines so you’re not scrambling in the final weeks.

receptionist looking at a tablet

Overlooking the Cost Category

The MIPS cost category doesn’t require data submission, so many providers ignore it. But it accounts for a significant portion of your final score. CMS calculates this using Medicare claims data based on the efficiency of the care you provide.

High costs relative to your peers will drag down your score, even if you’re excelling in other categories. You can influence this by reducing unnecessary procedures, coordinating care more effectively, and reviewing your billing patterns.

Not Reviewing Performance Feedback Reports

CMS provides performance feedback when you log into QPP after each reporting cycle, but many providers skip over logging in to review their scores. These reports show you where you scored well and where you fell short. Ignoring them means you’re missing valuable insights that could help you improve next year.

What the QPP Performance Feedback dashboard reveals:

Performance breakdown by category and measure
Specific areas where you lost points
Benchmark comparisons against peers

Take time to review your feedback when available. Look for patterns and identify which measures need more attention.

Ignoring Improvement Activities Documentation

The Improvement Activities category is often seen as the easiest part of MIPS, but providers still need proper documentation. You need to prove you actually completed the activities you’re claiming in the event of a CMS audit.

Documentation requirements vary by activity, but you generally need to show completion for at least 90 consecutive days. This might include meeting notes, training records, or patient engagement data.

Keep detailed records throughout the year. Store your documentation in an organized system where you can easily access it when submitting.

Skipping the Promoting Interoperability Category

For eligible providers, the Promoting Interoperability category is required. Yet some practices skip it or submit incomplete data because they don’t understand the requirements. This category focuses on electronic quality reporting and meaningful use of certified EHR technology- CEHRT.

If you don’t report when required, or you skip required measures within the category, it can significantly lower your overall MIPS score by 25 points! Many measures involve patient engagement, like providing access to health information or using secure messaging.

woman in blue scrub suit using macbook pro

Not Utilizing Available Reporting Tools

Manual data entry is time-consuming and prone to errors. Many providers still rely on spreadsheets or outdated systems that don’t integrate with their EHR.

Using automated reporting tools can save time and reduce mistakes. These systems pull data directly from your EHR, calculate scores in real time, and flag potential issues before you submit.

Look for platforms that offer EHR integration, real-time analytics, and support throughout the reporting process.

Misunderstanding MVPs vs. Traditional MIPS

The MIPS Value Pathways (MVP) framework simplifies reporting by aligning measures within a specialty or condition. But many providers don’t fully understand how MVPs work or whether they should use them instead of traditional MIPS.

MVPs require fewer measures, but those measures must be specific to the pathway you choose. If your data doesn’t match the required measures, your submission could be rejected. Review the MIPS essentials and compare measure requirements before deciding which reporting option to use.

Neglecting Quality of Clinical Documentation

Poor clinical documentation can undermine your MIPS performance. If your documentation doesn’t support the care you provided, it won’t count toward your quality measures.

Missing details, vague notes, or incomplete records can result in measures that don’t get counted. Improving documentation quality has a direct impact on patient care and your ability to demonstrate that care in MIPS reporting.

Ready to streamline your reporting process and avoid common MIPS reporting mistakes? Explore ACO reporting solutions that can help you stay compliant and maximize your MIPS performance.

Conclusion

MIPS and MVP documentation require attention to detail, but the most common mistakes are avoidable. By verifying measure eligibility, tracking data completeness throughout the year, meeting deadlines, and using the right tools, you can improve your scores and avoid penalties. Regular review of feedback reports and proper documentation practices will set you up for success in future reporting cycles.