06/17/2025

QPP

Improvement Activities Performance Category - CY 2025 Call for Improvement Activities Submission Form
Improvement activities recommended for inclusion or modification should be sent using the Improvement Activities Submission Template (below) to the email CMSCallforActivities@abtassoc.com. Stakeholders will receive an email confirmation for their submission. Improvement activities submitted between now and July 1, 2025, will be considered for inclusion for the CY 2027 performance period/2029 MIPS payment year. Improvement activities submitted after July 1, 2025, will be considered for inclusion in future years of the Quality Payment Program. During a public health emergency (PHE), nominations will be accepted outside of the February 1 through July 1 submission period as long as the improvement activity is relevant to the PHE. All fields of this form must be completed in order for your submission to be considered. Stakeholders should submit a modification submission QPP Resource Library if the improvement activity they submitted or one that refers to a program or policy they manage requires an update.

We also refer submitters to the 2025 MIPS Improvement Activities list on the CMS Quality Payment Program Resource Library, which lists the complete Inventory of current improvement activities for the CY 2025 performance period/2027 MIPS payment year. Submitters should ensure that proposed new activities do not duplicate existing ones.

MIPS improvement activities considered for selection must meet all 8 of the required acceptance criteria below:

Relevance to an existing improvement activities subcategory (or a proposed new subcategory)
Importance of an activity toward achieving improved beneficiary health outcomes
Feasible to implement, recognizing importance in minimizing burden, including, to the extent possible, for small practices, practices in rural areas, or practices in areas designated as geographic Health Professional Shortage Areas (HPSAs) by the Health Resources and Services Administration (HRSA)
Evidence supports that an activity has a high probability of contributing to improved beneficiary health outcomes
Can be linked to existing and related MIPS quality, Promoting Interoperability, and cost measures as applicable and feasible
CMS is able to validate the activity
Does not duplicate other improvement activities in the Inventory
Should drive improvements that go beyond purely common clinical practices

MIPS improvement activities considered for selection can also meet one or more of the optional acceptance criteria below. Meeting one or more of the optional criteria may increase a submission’s chances of being added to the Inventory:

Alignment with patient-centered medical homes
Support for the patient’s family or personal caregiver
Responds to a PHE as determined by the Secretary
Addresses improvements in practice to reduce health care disparities
Focus on meaningful actions from the person and family’s point of view
Representative of activities that multiple individual MIPS eligible clinicians or groups could perform (for example, primary care, specialty care)

Stakeholders should submit a modification submission via the Call for IA Submission Form (file download) if the improvement activity they submitted or one that refers to a program or policy they manage requires an update.”

2025 MIPS Exception Application Now Available
The 2025 Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances Exception application is available now through December 31, 2025, at 8 p.m. ET. This application allows users to indicate the reason they’re unable to report data for one or more MIPS performance categories.

There are two types of exception applications that allow users to indicate the reason they’re unable to report data for one or more MIPS performance categories.

Individual clinicians, groups, and virtual groups (or a third-party representative) can submit a MIPS Extreme and Uncontrollable Circumstances (EUC) exception application for one or more MIPS performance categories (quality, cost, improvement activities, and Promoting Interoperability) due to extreme and uncontrollable circumstances, defined as rare events entirely outside of your control and the control of the facility in which you practice.

These circumstances would:

Cause you to be unable to collect information necessary to submit for a MIPS performance category.
Cause you to be unable to submit information that would be used to score a MIPS performance category for an extended period of time (for example, if you were unable to collect data for the quality performance category for 3 months).
Impact your normal processes, affecting your performance on cost measures and other administrative claims measures.

2. Alternate Payment Model (APM) Entities participating in a MIPS APM can submit applications as well, but they must apply for all performance categories.

If your application is approved, you won’t be required to report data for the performance category or categories included in your approved application. However, please note that a qualifying data submission will override approved reweighting on a category-by-category basis. We’ll score any qualifying data that you, or someone on your behalf, submits, and those performance categories will contribute to your final score.

How to Apply
To submit either exception application:

Sign in to the QPP website with your Health Care Quality Information System (HCQIS) Access Roles and Profile (HARP) account.
Choose “Exceptions Application” from the left-hand navigation.
Click “Add New QPP Exception” on the right side of the screen.
Choose “Extreme and Uncontrollable Circumstances Exception.”

Additional Resources

Quality Payment Program Access User Guide (file download)
- Refer to “Step 1: Register for a HARP Account.”
Exception Applications (webpage on the QPP website)
2025 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide (file download)

2025 MIPS Value Pathways (MVPs) Registration Now Open
The MVPs registration window is open for the 2025 performance year. Individuals, groups, subgroups, and Alternative Payment Model (APM) Entities that want to report an MVP can register until December 1, 2025, at 8 p.m. ET.

*Note: If the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey is an available measure in your selected MVP and you want to administer it as 1 of your 4 required measures, you‘ll need to complete both your MVP registration and a separate CAHPS for MIPS Survey registration by June 30, 2025, at 8 p.m. ET.

To register, you’ll sign in to the QPP website with your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) account.

You must have a HARP account and a QPP Security Official role to complete the MVPs registration.

For more information on HARP accounts, please refer to the STEP 1. Register for a HARP Account document in the QPP Access User Guide (file download).
For more information on obtaining the QPP Security Official role, review the Step 2a. Connect to an Organization document in the QPP Access User Guide (file download).

Prepare for MVP Registration
To help you prepare for MVP registration, please refer to the 2025 MVPs Implementation Guide.

Want to learn more about the available MVPs for the 2025 performance period? Visit the Explore MVPs page.

How to Register
Individuals, groups, subgroups, and APM Entities will register on the QPP website. You’ll need to have the Security Official role to register your organization. Please refer to the QPP Access User Guide (file download) for information about obtaining a Security Official role for your organization. To register:

Sign in to QPP.
Click Register or Edit an MVP Registration from the landing page.
Click your MVP reporting option.

2025 Consumer Assessment of Healthcare Providers Survey (CAHPS) for MIPS Survey Registration Now Open
Registration is open through June 30, 2025, at 8 p.m. ET for the CAHPS for MIPS Survey for the 2025 performance year.

Groups, virtual groups, subgroups, and APM) Entities with 2 or more clinicians (including at least one MIPS eligible clinician) can register to administer the CAHPS for MIPS Survey for traditional MIPS, APM Performance Pathway (APP), or MVPs reporting.

Who doesn’t need to register?

Medicare Shared Savings Program Accountable Care Organizations (ACOs)
These ACOs are required to report through the APP so they’re automatically registered for the CAHPS for MIPS Survey, which is required under the APP.
These ACOs don’t need to register but will still need to hire a CMS-approved vendor to administer the CAHPS for MIPS Survey.

Who must register?

Groups and APM Entities (other than Shared Savings Program ACOs) that choose to report through the APP must register because the CAHPS for MIPS Survey is a required measure under the APP.

Who can register?

Groups, virtual groups, and APM Entities that intend to administer the CAHPS for MIPS Survey as 1 of their 6 quality measures for reporting traditional MIPS
Groups, subgroups, and APM Entities that are registered to report the following MVPs and that intend to administer the CAHPS for MIPS Survey as 1 of their 4 quality measures:
Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP
Advancing Cancer Care MVP
Value in Primary Care MVP

How to Register
Groups, virtual groups, and APM Entities will register on the QPP website. You’ll need to have the Security Official role to register your organization. Please refer to the QPP Access User Guide (file download) for information about obtaining a Security Official role for your organization. To register:

Sign in to QPP.
Click Start Registration from the landing page.
Click Register or Edit CAHPS Registration.

Subgroups interested in administering the CAHPS for MIPS Survey as 1 of their 4 required quality measures will need to complete their MVP registration prior to registering for the CAHPS for MIPS Survey. After completing the subgroup’s MVP registration, they will need to contact the QPP Service Center by email at QPP@cms.hhs.gov, by creating a QPP Service Center ticket, or by phone at 1‑866‑288‑8292 (Monday through Friday, 8 a.m. – 8 p.m. ET) to register for the CAHPS for MIPS Survey.

You must register by 8 p.m. ET on June 30, 2025.

Additional Resource

2025 CAHPS for MIPS Survey Registration Guide

Preview is Open
The Doctors and Clinicians Preview Period is open officially as of Tuesday, May 27, 2025. You can now preview your 2023 Quality Payment Program (QPP) performance information before it appears on the profile pages of clinicians and groups on the Medicare.gov compare tool and in the Provider Data Catalog (PDC). You can access the secure preview on the QPP website.

To learn how to preview your information, review the following resource:

2023 Doctors and Clinicians Performance Information: Guide to the Preview Period

For more help accessing the QPP website or getting your Health Care Quality Improvement Systems (HCQIS) Access Roles and Profile (HARP) user role, email the QPP Service Center at QPP@cms.hhs.gov. To learn how to sign up for a HARP account, review the QPP Access User Guide (file download).

To learn more about the 2023 QPP performance information available for preview, download the following resources on the Care Compare: Doctors and Clinicians Initiative webpage and in the 2023 Doctors and Clinicians Preview Period file (file download). on the QPP Resource Library:

Note that Accountable Care Organization (ACO) data isn’t available on the QPP website during the Preview Period. Merit-based Incentive Payment System (MIPS) eligible clinicians who participate in Medicare Shared Savings Program ACOs can preview their performance information in their 2023 MIPS Performance Feedback.

Medicare Shared Savings Program ACOs can also review quality performance information in their previously provided 2023 Quality Performance Reports. The list of ACO performance information planned for public reporting is available on the Care Compare: Doctors and Clinicians Initiative webpage and in the QPP Resource Library.

The 2023 Preview Period will close Wednesday, June 25, 2025, at 8 p.m. ET (5 p.m. PT).

Note that the 2023 QPP performance information planned for public reporting in 2025 will be added to the profile pages of clinicians and groups on the compare tool on Medicare.gov and in the PDC.

If you have any questions about public reporting of clinicians and groups on the compare tool on Medicare.gov, contact the QPP Service Center by emailing QPP@cms.hhs.gov, submitting a QPP Service Center ticket, or calling 1-866-288-8292 (Monday–Friday, 8 a.m.–8 p.m. ET).

People who are deaf or hard of hearing can call 711 to connect with a Telecommunications Relay Services (TRS) Communications Assistant.

Complete Story

06/17/2025

QPP