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CMS 2023 Quality Payment Program for Clinical Social Workers

By Denise Johnson, LCSW-C, Senior Practice Associate, Clinical Social Work


The Centers for Medicare and Medicaid Services (CMS) has announced updates to the Quality Payment Program (QPP) which can be found in the 2023 Physician Fee Schedule (PFS) and the QPP Resource Library. This document provides updates that are pertinent to clinical social workers (CSWs).

The QPP was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CSWs participate through the Merit-based Incentive Payment Program known as MIPS.2022 was the first year CSWs were considered MIPS eligible clinicians.

Through MIPS, CSWs and other eligible clinicians who are reimbursed for Medicare Part B services, receive a bonus for improving the quality of patient care and health outcomes. They are scored on the following performance areas:

  • Quality (30%)
  • Cost (30%)
  • Improvement activities (15%)
  • Promoting Interoperability (25%) (Information and data exchange with health systems, and provider to patient exchange)

Eligibility Requirements

To participate in MIPS, a CSW must exceed the following annual low-volume threshold as an individual or group:

  • Bill more than $90,000 Medicare Part B covered professional services
  • Provide more than 200 covered professional services to Medicare Part B patients
  • See more than 200 Medicare Part B patients

CSWs who exceed the low volume thresholds in solo or group practice are required to participate in MIPS. Through the use of measures, CMS provides CSWs with a bonus incentive to provide quality care. However, if measures are reported incorrectly, they may receive a negative penalty adjustment.


MIPS Transition to Value Pathways

Limited changes to traditional MIPS have been made in favor of CMS moving forward with implementing MIPS Value Pathways (MVPs). Beginning 2023, MVP measures will be used to meet MIPS reporting requirements. MVPs aim to align and connect measures and activities across the quality, cost, improvement activities, and performance categories of MIPS for different specialties, clinical conditions, or episodes of care. CMS believes the transition to MIPS MVPs will streamline program requirements, improve patient outcomes, and reduce provider burden.

MVPs are now available for voluntary reporting beginning with the 2023 MIPS performance year. CSWs can also meet MIPS reporting requirements through traditional MIPS. CMS has not finalized a timetable when traditional MIPS will not be available. The plan is to sunset traditional MIPS through future rulemaking.

CMS is providing opportunities for interested parties to participate in an annual public webinar to discuss potential MVP revisions that have been identified as feasible. More information on this topic can be found by visiting the MVP maintenance process webpage.

The MVP maintenance process allows stakeholders and the general public the opportunity to recommend changes to previously finalized MVPs which may be submitted via email. CMS will use the Physician Fee Schedule (PFS) rulemaking process to make any changes they deem to be warranted.


MVPs and Measures

CSWs and other healthcare professionals participate in MVPs that are relevant to their specialty practice or condition and select from a set of CMS approved quality measures and activities. An MVP participant will receive a final score based on the same performance category weights used in traditional MIPS, and the same performance category weight redistribution policies apply. In the 2022 ruling, 15 quality measures were finalized for CSWs. In 2023 CMS is adding a Screening for Social Drivers of Health (SDH) measure in the CSW specialty set. SDHs are a key component to a patient achieving health equity within clinical settings and clinician types. CMS plans to announce an updated list of CSWs measures in early 2023. NASW will inform members of this list as soon as it is available.

MIPS MVP Participants

CMS defines MIPS MVP participants as an

  • Individual clinician (Solo practice)
  • Specialty Group - one specialty type determined by CMS using Medicare Part B claims.
  • Multispecialty group - two or more specialties as determined by CMS using Part B claims.
  • Subgroup – a subset of clinicians (at least 2) in a group that has at least one MIPS eligible clinician. (Group practice)

CSWs may decide which group they prefer to participate in. Reporting for subgroups would be voluntary during the 2023 to 2025 performance periods. Effective 2026, multispecialty groups will be required to form subgroups to report MVPs.


Measure Scoring and Reporting 

The threshold to avoid a penalty will remain at 75 points. This means MIPS eligible clinicians and groups would need to reach a score of 75 to avoid a negative payment adjustment for the 2025 payment year. A positive pay adjustment will be given for scores 75.01 and above. The Data Completeness Threshold will increase from 70% to 75% for the 2024 and 2025 MIPS performance years. The 3-point floor for quality measures meeting data completeness and case minimum will be removed for large practices (i.e. >15 clinicians). This means quality measures for large practices would be scored on a 1-10 point scale versus a 3-10 point scale for small practices.

In 2023, CMS will retire the exceptional performance bonus. However, no changes are being made to the small practice bonus or the improvement score bonus. CMS will also allow facility-based eligible clinicians to be eligible for the complex patient bonus, even if they do not submit data for at least one MIPS performance category.


Medicare Compare Tools

CMS publicly reports QPP performance information for providers and groups on the Medicare Care Compare Doctors and Clinicians profile pages. As of 2023, the agency added a telehealth indicator to the Medicare Comparison Tools, to include information on how beneficiaries access care. The indicator is added on the clinician and group pages. CMS identifies clinicians performing telehealth services using claims data. Included is utilization data related to applicable conditions treated and procedures performed by individual or group providers.


How to Register

To report an MVP in performance year 2023, CSWs should register between April 1 and November 30, and select if they want to submit as a subgroup during this registration process. Registration cannot be changed once the deadline has passed. To complete registration, CSWs must sign into the QPP website. A registration guide will be available in early 2023 detailing step-by step instructions for registration.

To avoid a negative penalty adjustment and due to the complexities of reporting, NASW recommends using a mental health registry for the reporting of measures. A registry is a vendor that collects data from an eligible MIPS individual clinician or group and submits the data to Medicare on their behalf.  There is a fee associated with the use of a registry. Registries that report mental health and substance use disorder quality measures include, but are not limited to, the following:


For Help and Additional Information

CSWs are encouraged to contact the QPP Service Center at 1-866-288-8292, Monday through Friday, 8 am to 8 pm ET or by email at QPP@cms.hhs.gov. Assistance is also available from NASW by emailing Denise Johnson, LCSW-C, Senior Practice Associate, at djohnson.nasw@socialworkers.org