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Special status designations are used by CMS to categorize Eligible Clinicians (ECs) and their groups for participation and scoring purposes. CMS reviews past and current Medicare Part B Claims in two determination periods to assign special statuses:
Segment 1: Covers October 1, 2023 – September 30, 2024 (Initial Eligibility in December 2024)
Segment 2: Covers October 1, 2024 – September 30, 2024 (Final Eligibility in November 2025)
If you qualify for any special status in either of the segments, you will be assigned that special status for the reporting year.
Most anesthesiologists and their practices will receive special status designations as non-patient facing or hospital based. Check your participation status on the QPP website to see if any special statuses apply to you or your group.
Non-patient Facing
ECs reporting at the individual level are considered non-patient facing if they have 100 or fewer Medicare Part B patient-facing encounters, including telehealth services, within a determination period. Groups are deemed non-patient facing at the Taxpayer Identification Number (TIN) level if 75% or more ECs are considered non-patient facing as individuals.
If a clinician, practice, or virtual group is non-patient facing, they will receive 2x the points for each improvement activity when reporting a MIPS Value Pathway. They will also qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category or categories.
Historically, the majority of anesthesiologists have been identified by CMS as non-patient facing.
Hospital-based
A hospital-based MIPS eligible clinician means an individual MIPS eligible clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by place of service (POS) codes for an inpatient hospital, on-campus outpatient hospital, off campus outpatient hospital, or emergency room setting based on claims for the MIPS determination period (Place of Service codes 19, 21, 22, 23 respectively). A group or virtual group earns hospital-based status provided that more than 75 percent of the NPIs billing under the group's TIN or virtual group's TINs, as applicable, meet the definition of a hospital-based individual MIPS eligible clinician during the MIPS determination period.
If a clinician, practice, or virtual group is hospital-based, they qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category (or categories).
Facility-based
If you’re identified as facility-based, you may qualify for facility-based scoring. Under facility-based scoring, your assigned facility’s Hospital Value-Based Purchasing (VBP) Program score can be used for scoring the MIPS quality and cost performance categories in traditional MIPS without submitting additional quality measures.
This status is predictive. CMS will not know until the end of the performance year if your assigned facility has the Hospital VBP Program score needed for facility-based scoring. If your assigned facility doesn’t have a Hospital VBP Program score, you will need to report MIPS quality measures.
This facility-based status is based solely on claims from Segment 1 of the MIPS Determination Period (prior to the performance year). An individual or group cannot gain this status when we update eligibility after segment 2 of the MIPS Determination Period.
To be facility-based, the MIPS eligible clinician furnishes 75% or more of their covered professional services in a hospital setting (Place of Service (POS) codes 21, 22 or 23) AND bills at least one service in an inpatient hospital or emergency room AND is assigned to a facility that participates in the Hospital VBP Program. A group is considered facility-based when 75% or more of the clinicians billing under the practice’s TIN meet the definition of facility-based.
Ambulatory-Surgical Center (ASC)-based
ECs reporting at the individual level are hospital-based if they furnish 75% or more of their covered professional services in sites on service identified by Place of Service (POS) code 24. A group or TIN is considered ASC-based only if 100% of ECs are ASC-based as individuals. If a clinician, practice, or virtual group is ASC-based, they qualify for automatic reweighting of the Promoting Interoperability category.
If a clinician, practice, or virtual group is ASC-based, they qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category (or categories).
Small practice
Individual eligible clinicians and small practices may receive this special status if there are 15 or fewer clinicians who bill under the practice’s TIN. A clinician, practice or virtual group will earn 2x the points for each improvement activity they submit. Clinicians, practices, or virtual groups who submit at least one Quality measure will also receive six bonus points in the Quality performance category. Small practices are also eligible to receive three points for quality measures that are submitted but do not meet data completeness thresholds. They will also qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category or categories.
Rural
An EC, practice, or virtual group identified as "rural" will earn 2x the points for each improvement activity they submit. An eligible clinician will receive special status if the practice they are associated with is located in a rural area. A rural area means a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP), using the most recent FORHP Eligible ZIP Code file available. Practices with 75% or more of the clinicians billing under the practice’s TIN are in a zip code designated as rural using.
Individuals and groups designated as "rural" will also qualify for automatic reweighting of the Promoting Interoperability performance category to 0%. The 25% category weight will be redistributed to other performance categories unless you choose to submit Promoting Interoperability data.
Health Professional Shortage Area (HPSA)
An EC clinician, practice, or virtual group identified as working in an HPSA will earn 2x the points for each improvement activity they submit. A group that has at least one practice site under its TIN designated as an HPSA will receive this status and a virtual group will receive the HPSA special status if 75% or more of the clinicians billing in the virtual group are designated as an HPSA.
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Special status designations are used by CMS to categorize Eligible Clinicians (ECs) and their groups for participation and scoring purposes. CMS reviews past and current Medicare Part B Claims in two determination periods to assign special statuses:
Segment 1: Covers October 1, 2022 – September 30, 2023 (Initial Eligibility in December 2023)
Segment 2: Covers October 1, 2023 – September 30, 2024 (Final Eligibility in November 2024)
If you qualify for any special status in either of the segments, you will be assigned that special status for the reporting year.
Most anesthesiologists and their practices will receive special status designations as non-patient facing or hospital based. Check your participation status on the QPP website to see if any special statuses apply to you or your group.
Non-patient Facing
ECs reporting at the individual level are considered non-patient facing if they have 100 or fewer Medicare Part B patient-facing encounters, including telehealth services, within a determination period. Groups are deemed non-patient facing at the Taxpayer Identification Number (TIN) level if 75% or more ECs are considered non-patient facing as individuals.
If a clinician, practice, or virtual group is non-patient facing, they will also qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category or categories.
Historically, the majority of anesthesiologists have been identified by CMS as non-patient facing.
Hospital-based
A hospital-based MIPS eligible clinician means an individual MIPS eligible clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by place of service (POS) codes for an inpatient hospital, on-campus outpatient hospital, off campus outpatient hospital, or emergency room setting based on claims for the MIPS determination period (Place of Service codes 19, 21, 22, 23 respectively). A group or virtual group earns hospital-based status provided that more than 75 percent of the NPIs billing under the group's TIN or virtual group's TINs, as applicable, meet the definition of a hospital-based individual MIPS eligible clinician during the MIPS determination period.
If a clinician, practice, or virtual group is hospital-based, they qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category (or categories).
Facility-based
If you’re identified as facility-based, you may qualify for facility-based scoring. Under facility-based scoring, your assigned facility’s Hospital Value-Based Purchasing (VBP) Program score can be used for scoring the MIPS quality and cost performance categories in traditional MIPS without submitting additional quality measures.
This status is predictive. CMS will not know until the end of the performance year if your assigned facility has the Hospital VBP Program score needed for facility-based scoring. If your assigned facility doesn’t have a Hospital VBP Program score, you will need to report MIPS quality measures.
This facility-based status is based solely on claims from Segment 1 of the MIPS Determination Period (prior to the performance year). An individual or group cannot gain this status when we update eligibility after segment 2 of the MIPS Determination Period.
To be facility-based, the MIPS eligible clinician furnishes 75% or more of their covered professional services in a hospital setting (Place of Service (POS) codes 21, 22 or 23) AND bills at least one service in an inpatient hospital or emergency room AND is assigned to a facility that participates in the Hospital VBP Program. A group is considered facility-based when 75% or more of the clinicians billing under the practice’s TIN meet the definition of facility-based.
Ambulatory-Surgical Center (ASC)-based
ECs reporting at the individual level are hospital-based if they furnish 75% or more of their covered professional services in sites on service identified by Place of Service (POS) code 24. A group or TIN is considered ASC-based only if 100% of ECs are ASC-based as individuals. If a clinician, practice, or virtual group is ASC-based, they qualify for automatic reweighting of the Promoting Interoperability category.
If a clinician, practice, or virtual group is ASC-based, they qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category (or categories).
Small practice
Individual eligible clinicians and small practices may receive this special status if there are 15 or fewer clinicians who bill under the practice’s TIN. A clinician, practice or virtual group will earn 2x the points for each improvement activity they submit. Clinicians, practices, or virtual groups who submit at least one Quality measure will also receive six bonus points in the Quality performance category. Small practices are also eligible to receive three points for quality measures that are submitted but do not meet data completeness thresholds. They will also qualify for automatic reweighting of the Promoting Interoperability category to 0%. If no Promoting Interoperability data is submitted, the 25% category weight will be redistributed to another performance category or categories.
Rural
An EC, practice, or virtual group identified as "rural" will earn 2x the points for each improvement activity they submit. An eligible clinician will receive special status if the practice they are associated with is located in a rural area. A rural area means a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP), using the most recent FORHP Eligible ZIP Code file available. Practices with 75% or more of the clinicians billing under the practice’s TIN are in a zip code designated as rural using.
Individuals and groups designated as “rural” will also qualify for automatic reweighting of the Promoting Interoperability performance category to 0%. The 25% category weight will be redistributed to other performance categories unless you choose to submit Promoting Interoperability data.
Health Professional Shortage Area (HPSA)
An EC clinician, practice, or virtual group identified as working in an HPSA will earn 2x the points for each improvement activity they submit. A group that has at least one practice site under its TIN designated as an HPSA will receive this status and a virtual group will receive the HPSA special status if 75% or more of the clinicians billing in the virtual group are designated as an HPSA.
Curated by: ASA Department of Quality and Regulatory Affairs
Date of last update: December 16, 2024