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Key Findings

In Pictures

These five charts carry the paper’s argument. Figure 1 sets how often each specialty’s Medicare-billing clinicians appear in MIPS against how many clear MIPS’s minimum-volume tests on their own billing. Figure 2 shows how average payment adjustments moved from 2019 to 2024, Figure 3 shows the 2024 final and category scores behind them, and Figure 4 shows that the negative averages come mainly from records that submitted no data. Figure 5 brings these together in one schematic of how MIPS works and where chiropractic stands at each step. Scores and adjustments are simple averages across clinician–practice records; they are not weighted by Medicare dollars and are not any one clinician’s result.

Figure 1. MIPS representation relative to individual volume-threshold attainment, 15 specialties, 2024. Horizontal axis: share of clinicians billing Original Medicare whose own annual billing exceeds all three MIPS minimum-volume tests (more than $90,000 in allowed charges, more than 200 Medicare patients and more than 200 services). Vertical axis: distinct clinicians in the MIPS public data as a share of those billing Original Medicare. Bubble size: clinicians billing Original Medicare. Specialties above the dashed diagonal appear in the MIPS data more often than individual threshold attainment alone would predict. Chiropractic (0.5% exceeding all tests; 1.03% in the MIPS data) sits on the diagonal near the origin, while the low-volume professions in the outlined area, including physical therapy (3.4%; 21.79%) and clinical social work (0.3%; 24.02%), sit well above it. This pattern is consistent with additional participation pathways, including group-based eligibility and reporting, but does not establish the mechanism. The volume tests are approximated from annual billing totals, the two sources are not linked clinician by clinician, and the vertical axis is not a MIPS participation rate. Source: CMS Medicare Physician & Other Practitioners file and QPP public use file via Mimilabs, SQL3 and SQL4. Visualization was human generated.

Figure 2. Average MIPS payment adjustment by specialty, performance years 2019–2024. Adjustments apply to Medicare Part B payments two years after the performance year. Chiropractic (blue) and podiatry (red) moved from positive averages in 2019–2021 to negative averages in each of 2022–2024, reaching −1.738% and −1.784% in 2023. No other specialty averaged below −0.5% in any year shown: two others were slightly negative in 2023 and four in 2024. Physical therapy (purple) peaked at +2.825% in 2022 and fell to +0.186% in 2024. Clinical social work (orange) is shown from 2022, its first year as an eligible clinician type. The 2022 turn coincides with the performance threshold reaching 75 points (from 30 in 2019) and with the last performance year of the exceptional-performance bonus. Values are simple averages across clinician–practice (TIN/NPI) records, not weighted by Medicare payments; changes in program rules and in which clinicians appear in the file limit causal interpretation. Source: CMS QPP public use file via Mimilabs, SQL1; thresholds from 42 CFR 414.1405. Visualization was human generated.

Figure 3. Average MIPS final score and performance category scores by specialty, 2024. Chiropractic (blue; 335 records) averaged a final score of 69.94, below the 75-point threshold and 14th of 15, ahead of only podiatry (red; 7,873 records; 67.39); physical therapy (purple; 17,692 records) averaged 83.37. Chiropractic’s quality score (51.73) was also 14th, against 74.11 for physical therapy, while its cost score (62.61) was third highest, near physical therapy’s (65.15) and well above podiatry’s (20.00), and its interoperability score (58.81) was above both. Improvement activities scores were rescaled from their 0–40 range to 0–100 for display. Scores are simple averages across clinician–practice (TIN/NPI) records with a value in the public file. Category weights, applicability and reweighting differ among clinicians, so category averages cannot be combined to reproduce the final score or to show each category’s contribution to payment adjustments. Cost scores reflect performance on applicable CMS resource-use measures, not absolute treatment costs, and CMS changed cost scoring for 2024, so they should not be compared with earlier years. Source: CMS QPP public use file via Mimilabs, SQL1. Visualization was human generated.

Figure 4. Average MIPS payment adjustment by reporting status, chiropractic, podiatry and physical therapy, 2024. Bars show each specialty’s average overall and separately for records that reported and records flagged as nonreporting. Chiropractic and podiatry had negative overall averages (−1.24% and −1.52%) and physical therapy a positive one (+0.19%). Records that reported averaged near zero or above in all three (−0.11% chiropractic, +0.12% podiatry, +0.35% physical therapy), while nonreporting records averaged −4.98%, −4.56% and −3.95%. Chiropractic and podiatry also had far higher shares of nonreporting records (23.3% and 35.0%) than physical therapy (3.7%), so nonreporting appears to be the main driver of their negative overall averages: had chiropractic nonreporters averaged the same as chiropractic reporters, the chiropractic average would have been about −0.11% rather than −1.24%. The 2022 and 2023 pattern was similar (Table 7). Values are simple averages across clinician–practice (TIN/NPI) records in the MIPS public use file, not weighted by Medicare payments. These data do not show why records were nonreporting or what nonreporting records would have received had they submitted data. Source: CMS QPP public use file via Mimilabs, SQL1 (overall) and SQL5 (by reporting status). Visualization was human generated.

Figure 5. How MIPS works, and where chiropractic stands, 2024. Each row is a step in the program (billing Medicare, eligibility, appearing in MIPS, reporting, scoring and payment adjustment), with the rule in the first column and chiropractic and physical therapy results in the next two; the right-hand column gives the Author’s interpretation. Of 32,394 chiropractors billing Original Medicare, 0.5% exceeded all three minimum-volume tests on their own billing and 333 (1.03%) appeared in the MIPS data, mostly through groups, although 63.7% of Medicare-enrolled chiropractors belonged to no enrolled group; physical therapists appeared about 21 times as often (21.79%). Of chiropractic MIPS records, 23.3% were nonreporting, 6.3 times the physical therapy share (3.7%), and averaged −4.98%, against −0.11% for records that reported; nonreporting contributed −1.16 of the −1.24-point average (about 93%). Stages 1–2 count clinicians in the Medicare billing file (group membership from the Doctors and Clinicians file, December 2023), and Stages 3–6 count MIPS clinician–practice records; the files are not linked clinician by clinician. Route counts are approximate, derived from rounded percentages. Category weights are for traditional MIPS without reweighting. Source: CMS via Mimilabs, SQL1, SQL3–SQL5, SQL10 and SQL11; program rules from CMS and cited secondary sources. Visualization was human generated.

Arete's Take

At a Glance

Table 1. At a Glance: chiropractic compared with 14 other specialties

MIPS records are clinician–practice (TIN/NPI) combinations; one clinician can appear under more than one practice. Medicare-billing clinicians are distinct NPIs in the CMS Medicare Physician & Other Practitioners file. Source: CMS via Mimilabs, SQL1–SQL5. SQL4 approximates the volume tests.

Abstract

Background. The Merit-based Incentive Payment System (MIPS), part of Medicare’s Quality Payment Program, scores eligible clinicians each year and raises or lowers their Medicare Part B payments two years later. Specialty-level MIPS results are sometimes read as signals of a profession’s quality. Those results describe only the clinicians who appear in the program’s public data, which can be a small and unrepresentative part of a profession. As a follow-up to A Decade of Divergence and The Denial Paradox, this paper examines how many chiropractors MIPS reaches and how they fare.

Methods. Retrospective, descriptive analysis of the CMS QPP public use file for performance years 2017–2024, accessed through Mimilabs, for chiropractic and 14 comparator specialties. Distinct clinician NPIs in the file were compared with distinct NPIs billing Original Medicare under the same specialty. Average final scores, category scores, payment adjustments and status flags were summarized by specialty and year, and payment adjustments were split by reporting status for chiropractic, physical therapy and podiatry. Each specialty’s clinician-level Medicare billing totals were compared with MIPS’s minimum-volume tests. Group membership among Medicare-enrolled clinicians was taken from the CMS Doctors and Clinicians file (December 2023), and MIPS records were classified by participation option. Averages are across clinician–practice records and are not weighted by Medicare payments.

Results. In 2024, 333 chiropractors appeared in the MIPS data, 1.03% of the 32,394 billing Original Medicare; the other 14 specialties ranged from 21.79% to 54.36%. An estimated 99.5% of chiropractors billing Medicare in 2024 were at or below at least one minimum-volume test, but six other specialties were nearly as low-volume (92.8% to 99.7%) and still had 22% to 41% of their clinicians in MIPS. Relative to the number exceeding all tests on their own billing, MIPS reached about 2.1 chiropractors per such clinician, against 4.8 to about 80 for those six specialties. In December 2023, 63.7% of Medicare-enrolled chiropractors belonged to no enrolled group, the highest share of the 15 specialties, against 7.0% of physical therapists, and grouped chiropractors were in small groups (median 3 clinicians, against 42). Within MIPS, most records in every specialty, including chiropractic (67.1% in 2023), participated through a group or APM entity. The chiropractic count in MIPS fell 73.3% from 2019, the largest decline of the 14 specialties eligible in both years, and after 2021 shifted away from small practices and toward hospital-based status. Chiropractic’s average payment adjustment (−1.738% in 2023; −1.244% in 2024) was second lowest of the 15 specialties, after podiatry. In 2023, the 22% of chiropractic records flagged as nonreporting averaged −7.48%; the records that reported averaged −0.14%, about 8% of the overall average. Physical therapy and podiatry reporters averaged +0.90% and +0.32%. Reporters who lacked interoperability reweighting and scored zero on that category, the only group a missing certified EHR could penalize, were 12 records and accounted for −0.15 points; among chiropractors in MIPS, 50.7% reported a certified EHR, a typical share.

Conclusions. MIPS reaches about 1 in 100 chiropractors who bill Original Medicare. Nearly all fall below its minimum-volume tests, but so do most clinicians in several other professions that MIPS reaches far more often, mainly through groups. Most chiropractors belong to no Medicare-enrolled group, and those who do are in very small ones, which supports an organizational as well as a volume-related explanation for chiropractic’s distance from MIPS; the files are not linked clinician by clinician, so individual routes are not observed. Among the few it scores, the negative average is driven mostly by records that submitted no data; chiropractors who reported averaged close to no adjustment. These aggregate data cannot show why records were nonreporting or what any practice actually gained or lost.

Methods

Design, data sources, and unit of analysis

This is a national, repeated cross-sectional, descriptive analysis of the CMS Quality Payment Program (QPP) public use file for MIPS performance years 2017 through 2024, accessed through the Mimilabs mirror (table mimi_ws_1.datacmsgov.qpp). Each row in the file is a clinician–practice combination: a clinician’s National Provider Identifier (NPI) billing under a practice’s Taxpayer Identification Number (TIN). One clinician can appear under more than one TIN. CMS excludes TIN/NPI combinations with fewer than 11 patients from the public file. Counts of clinicians in this paper use distinct NPIs; averages and percentages use TIN/NPI records.

The comparison population is the CMS Medicare Physician & Other Practitioners file by provider (Mimilabs table mimi_ws_1.datacmsgov.mupphy_prvdr), which lists clinicians who billed Original Medicare Part B. For each specialty and year, the number of distinct rendering NPIs was counted. The year was taken from the Mimilabs source-file date (YEAR(mimi_src_file_date)); the Mimilabs table documentation states that this date marks the service year (for example, 2022-12-31 for 2022 data), per the Author’s check.

Group membership came from the CMS Doctors and Clinicians National Downloadable File (Mimilabs table mimi_ws_1.provdatacatalog.dac_ndf), December 1, 2023 snapshot, which lists each Medicare-enrolled clinician’s primary specialty and any Medicare-enrolled group practice (PECOS group) with its number of members. A clinician was counted as in no group if none was listed and otherwise by the largest group listed. Specialty in this file is the clinician’s self-reported primary specialty at enrollment, not the billing-derived provider type used elsewhere, and the file includes enrolled clinicians who did not bill (38,414 enrolled chiropractors against 33,147 billing in 2023). MIPS eligibility is determined by tax ID (TIN), which is close to but not the same as a PECOS group.

Specialties

Fifteen specialties were selected in advance: chiropractic, physical therapy (physical therapist in private practice), orthopedic surgery, pain medicine (pain management and interventional pain management combined), physical medicine and rehabilitation (PM&R), family medicine, internal medicine, emergency medicine, nurse practitioner, physician assistant, optometry, clinical psychologist, clinical social worker, podiatry, and psychiatry (including geriatric psychiatry). In the 2024 QPP file, many specialty labels begin with “Physician/”; that prefix was removed before mapping. The Medicare billing file uses the matching provider-type labels. Two specialty-years are absent from the QPP file (clinical social worker, 2020 and 2021); they are treated as missing, not zero.

Measures

For each specialty and year: MIPS records (TIN/NPI rows); MIPS clinicians (distinct NPIs); Medicare-billing clinicians (distinct NPIs in the billing file); and the share of Medicare-billing clinicians in the MIPS data (MIPS clinicians divided by Medicare-billing clinicians). Averages were calculated for the MIPS final score (0–100), the payment adjustment percentage, and the four performance category scores (quality, Promoting Interoperability, improvement activities, and cost). Percentages of records were calculated for status flags, including nonreporting, small practice, rural, health professional shortage area, hospital-based, Promoting Interoperability reweighting, extreme and uncontrollable circumstances, opt-in, and safety-net status. Averages exclude missing values; flag percentages use all records. No average is weighted by Medicare payments.

Supplementary queries

Further queries were run by the Author in Mimilabs. SQL4 compared each clinician’s annual totals in the Medicare billing file (allowed amount, beneficiaries and services) with the MIPS minimum-volume tests for all 15 specialties, 2019–2024, and reported the share at or below each test, the share above all three, and medians. This is an approximation: CMS applies the tests to each TIN/NPI combination and to groups, over its own two determination periods, and counts only covered professional services, and the billing file omits clinicians with fewer than 11 beneficiaries. SQL5 split MIPS records for chiropractic, physical therapy and podiatry by the nonreporting flag, 2022–2024. Three related queries (SQL7a–c) examined the Promoting Interoperability category. SQL7a split 2022–2024 chiropractic, physical therapy and podiatry records by interoperability reweighting, nonreporting and interoperability score (above zero, zero or missing). SQL7b counted, for all 15 specialties in 2023 and 2024, the distinct NPIs with a certified EHR identifier (the cehrt_id field). SQL7c divided chiropractic records for 2022–2024 into four groups and computed each group’s contribution to the average payment adjustment. SQL8 split 2022–2024 chiropractic records by certified EHR identifier, interoperability reweighting and reporting status, with special-status shares, and SQL9 produced the 2023 contributions in Table 9. SQL10 classified 2023 and 2024 MIPS records for all 15 specialties by participation option (individual, group, virtual group or APM entity). SQL11 classified Medicare-enrolled clinicians by group membership and group size.

Program context

Chiropractors have been MIPS-eligible clinician types since the program began in 2017. Physical therapists and clinical psychologists were added in 2019, and clinical social workers in 2022. An eligible clinician or group is excluded from MIPS if it falls at or below a low-volume threshold. For 2017 the threshold was $30,000 in Part B allowed charges or 100 Part B beneficiaries. From 2018 it was $90,000 or 200 beneficiaries, and from 2019 a third test of 200 covered professional services was added; meeting any one test excludes the clinician unless it opts in. Clinicians who qualify through an advanced alternative payment model are also excluded. The Promoting Interoperability category (25% of the final score), which requires certified EHR technology, is automatically reweighted to zero for clinicians with special statuses, such as small practice (from 2022), hospital-based, ambulatory surgical center-based and non-patient-facing, and in some years for certain clinician types. For 2023, CMS listed clinical social workers, physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists and registered dietitians; from 2024, only clinical social workers remained. Chiropractors were not on either list, so a chiropractor with no special status and no certified EHR technology scores zero in that category unless granted a hardship exception.

A final score at the performance threshold receives no adjustment; scores above it receive a positive adjustment and scores below it a negative one, up to a maximum cut of 9% from performance year 2020 onward. The threshold was 3 points in 2017, 15 in 2018, 30 in 2019, 45 in 2020, 60 in 2021 and 75 from 2022 onward. Adjustments are budget-neutral and apply two years after the performance year. A separately funded additional adjustment for exceptional performance was available through performance year 2022. Clinicians can be scored as individuals or as part of a group or alternative payment model entity; in the public file, patient counts, allowed charges and special statuses are attributed according to how the clinician participated, so for group participants they describe the practice (TIN), not the individual.

Appendix A contains a MIPS participation checklist for chiropractic practices. The independent verification and reconciliation record and the full query text are kept in the internal master document maintained under the Arete Research Library Governance Framework.

Results

Very few chiropractors who bill Medicare appear in MIPS (Figure 1)

In 2024, 333 distinct chiropractors appeared in the MIPS public data, compared with 32,394 chiropractors billing Original Medicare (1.03%). The next-lowest specialty was physical therapy at 21.79% (16,974 of 77,901), and the highest was orthopedic surgery at 54.36% (Table 2). The 2023 pattern was the same: chiropractic 1.05%, all other specialties 22.87% to 56.34%. Because the comparison population includes clinicians who are not eligible for MIPS, this share is best read as how much of each specialty’s Medicare-billing workforce MIPS reaches, not how many eligible clinicians chose to take part.

Table 2. Share of Medicare-billing clinicians in the MIPS public data, 2023 and 2024

Distinct NPIs in both columns. Not a MIPS participation rate: the sources are not linked clinician by clinician, and the Medicare-billing count is not limited to MIPS-eligible clinicians. Source: CMS via Mimilabs, SQL3.

Low volume is common; staying outside MIPS is not (Figure 1)

In every year from 2019 to 2024, an estimated 99.2% to 99.5% of chiropractors billing Original Medicare were at or below at least one of MIPS’s minimum-volume tests. The dollar and patient tests did most of the work: in 2024, only 1.1% of chiropractors exceeded $90,000 in allowed charges and 2.1% exceeded 200 Medicare patients, while 74.3% exceeded 200 services; 0.5% exceeded all three. Physical therapists had a similar profile (19.2%, 4.1% and 95.8%; 3.4% above all three). Chiropractors had the lowest median allowed charges of the 15 specialties ($13,305 in 2024).

Low volume is not unique to chiropractic, however (Figure 1; Table 3). In 2024, clinical social workers (99.7%), physical therapists (96.6%), clinical psychologists (96.5%), psychiatrists (94.9%), nurse practitioners (93.0%) and physician assistants (92.8%) were also nearly all at or below at least one test. Yet 22% to 41% of the clinicians in each of those six specialties appeared in the MIPS data, against 1% of chiropractors. In Figure 1 these professions sit well above the diagonal, where representation would equal individual threshold attainment; chiropractic sits on it. Comparing the number of clinicians in MIPS with the number who exceed all three tests on their own billing makes the difference concrete: about 2.1 chiropractors per such clinician, compared with 4.8 to 8.2 for nurse practitioners, physician assistants, psychiatrists, physical therapists and clinical psychologists, and about 80 for clinical social workers. For the high-volume physician specialties (orthopedic surgery, pain medicine, podiatry, PM&R, internal and family medicine) the ratio was close to 1, meaning MIPS reached roughly the clinicians who would qualify on their own.

A ratio well above 1 means most clinicians in MIPS entered some other way than their own volume. The most likely route is group eligibility, in which the volume tests are applied to the practice’s combined billing, along with APM entities and opt-in. These data cannot show each clinician’s route, but group and APM participation account for most MIPS records in every specialty (Table 4). For chiropractic, the ratio fell from about 4.4 in 2019 to about 1.8 in 2022 and 2023 (about 2.1 in 2024; because 0.5% is a rounded value, the 2024 ratio could be anywhere from about 1.9 to 2.3), which is consistent with fewer chiropractors entering MIPS through groups after 2021. Results for 2023 were similar.

Table 3. Minimum-volume tests and MIPS reach by specialty, 2024, ordered by share exceeding all tests

Approximation: tests applied to each clinician’s annual totals in the Medicare billing file, not to CMS’s TIN/NPI determination periods or to groups; clinicians with fewer than 11 beneficiaries are not in the file. “Exceed all tests” is estimated from a rounded percentage, so small counts (clinical social workers, chiropractors) are imprecise. A ratio below 1 can occur when a clinician exceeds the tests in total but not under any single practice. MIPS data = distinct NPIs in the QPP public use file (SQL3). Source: CMS via Mimilabs, SQL3 and SQL4.

Most chiropractors belong to no group; most of their comparators belong to large ones (Table 4)

The Doctors and Clinicians file lists each Medicare-enrolled clinician’s group practice and its size. In December 2023, 63.7% of the 38,414 enrolled chiropractors belonged to no group, the highest share of the 15 specialties; the next highest were clinical psychologists (48.3%) and clinical social workers (36.2%). Chiropractors who did belong to a group were in small ones: the median group had 3 clinicians, and 0.9% of enrolled chiropractors were in groups of 100 or more. Physical therapists, who clear the volume tests on their own almost as rarely as chiropractors (Table 3), were the reverse: 7.0% belonged to no group, the median group had 42 clinicians, and 58.6% were in groups of 16 or more.

Within MIPS, most records in every specialty participated as part of a group or APM entity rather than individually. Physical therapy records were 89.5% group and 5.1% individual in 2023. Chiropractic records were also mostly group participants (67.1%), with 23.8% individual and 9.1% APM entity, so the few chiropractors in MIPS also mostly arrived through groups. Together, the two sources indicate that other low-volume professions reach MIPS mainly through groups, and that chiropractors rarely belong to groups, and almost never to large ones. As an arithmetic illustration only, three chiropractors at the 2024 chiropractic median ($13,305 in allowed charges) would together bill about $40,000, well below the $90,000 test. The two files are not linked clinician by clinician, so this describes specialties, not individual routes.

Table 4. Group membership among Medicare-enrolled clinicians (December 2023) and MIPS participation option (2023), by specialty, ordered by share in no group

Enrolled clinicians: distinct NPIs in the CMS Doctors and Clinicians file, December 1, 2023 snapshot, by self-reported primary specialty; a clinician in more than one group is counted by the largest. Group = Medicare-enrolled group practice (PECOS), whose size counts all member clinicians of any specialty; median group size is among grouped clinicians. MIPS columns are percentages of 2023 MIPS records (TIN/NPI); group or APM includes virtual groups. The two files are not linked. Source: CMS via Mimilabs, SQL10 and SQL11.

The chiropractic MIPS population shrank and changed

The number of chiropractors in the MIPS data fell from 4,429 in 2017 to 788 in 2018, when the low-volume threshold was raised, then rose to 1,245 in 2019 before falling every year to 333 in 2024 (Table 5). The 2019 to 2024 decline (−73.3%) was the largest of the 14 specialties eligible in both years. Declines were widespread, however: the other 13 ranged from −22.0% (physician assistant) to −59.0% (family medicine). Over the same period the number of chiropractors billing Original Medicare fell 8.0%, so the chiropractic share in MIPS fell from 3.53% to 1.03%.

The mix of chiropractic records also changed. Between 2021 and 2022, the small-practice share fell from 62.4% to 38.4% and the hospital-based share rose from 8.9% to 18.6% (20.7% in 2023). Applying these percentages to the record counts, small-practice records fell from about 590 to about 142 (−76%) while other records fell from about 356 to about 228 (−36%). No other specialty’s small-practice or hospital-based share moved by more than 8 percentage points between 2021 and 2022. The average number of Medicare patients attributed to each chiropractic record roughly doubled, from 7,706 to 14,523; because these counts describe the practice when a clinician participates as part of a group, larger values point to larger practices, not larger individual caseloads.

Table 5. Chiropractic in the MIPS public data, 2017–2024

Small practice, hospital-based and nonreporting are percentages of MIPS records. The 2017 file flags every record as nonreporting and is not comparable with later years. Source: CMS via Mimilabs, SQL1 and SQL3.

Scores and payment adjustments, 2023 and 2024 (Figure 2)

Chiropractic and podiatry were the only specialties with average final scores below 70 in both 2023 and 2024, and the only two below the 75-point threshold in 2024 (Table 6). They also had the two most negative average adjustments in both years. Four specialties averaged below zero in 2023 (podiatry, chiropractic, pain medicine and PM&R) and six in 2024 (adding optometry and orthopedic surgery). Positive averages were smaller in 2024 than in 2023 for every specialty that stayed positive.

As an arithmetic illustration only, on $100,000 of Medicare Part B payments subject to adjustment, the 2023 chiropractic average (−1.738%) equals −$1,738 and the physical therapy average (+0.691%) equals +$691, a difference of $2,429. This is not an estimate of any practice’s actual adjustment, because individual adjustments vary around these averages.

Table 6. Average final score and payment adjustment by specialty, 2023 and 2024, ordered by 2024 adjustment

Averages across TIN/NPI records, not weighted by Medicare payments. 2023 adjustments apply to 2025 payments; 2024 adjustments to 2026 payments. An average score below the threshold generally goes with a negative average adjustment, but the two averages are not linked one to one. Source: CMS via Mimilabs, SQL1.

Nonreporting accounts for most of the chiropractic cut (Figure 4)

Splitting records by the nonreporting flag changes the picture (Table 7). In 2023, the 77 chiropractic records flagged as nonreporting averaged −7.48% with an average score of 12.7, while the 276 that reported averaged −0.14% with a score of 76.2. Had the nonreporting records averaged the same as the reporters, the chiropractic average would have been about −0.14% rather than −1.74%; measured as each group’s contribution to the average, nonreporting records account for about 94% of the 2023 negative average (−1.63 of −1.74 points) and about 93% in 2024 (−1.16 of −1.24). In 2022, chiropractors who reported averaged +1.03%, so the negative overall average came entirely from nonreporting records. The 2024 comparison is shown in Figure 4: chiropractic reporters averaged −0.11% and nonreporters −4.98%, against +0.12% and −4.56% for podiatry and +0.35% and −3.95% for physical therapy.

Chiropractors who reported still did somewhat less well than reporters in the two comparison specialties. Their average scores (79.1, 76.2 and 80.9 in 2022–2024) were below those of podiatry reporters (81.4, 80.8, 83.8) and physical therapy reporters (87.0, 86.4, 84.9), and their average adjustments were slightly negative in 2023 and 2024 while the others were positive. Podiatry had a much larger share of nonreporting records (38.6% in 2023), and for podiatry nonreporting accounts for more than the entire negative average. Nonreporting records did not all receive the maximum 9% cut (chiropractic nonreporters averaged −7.48% in 2023), consistent with some receiving reweighting or exceptions. These data do not show why a record was nonreporting.

Table 7. Payment adjustment and final score by reporting status, 2022–2024

Adj. = average payment adjustment; Nonrep. = flagged as nonreporting. Averages across TIN/NPI records. Record counts and record-weighted averages of the two groups reproduce the SQL1 totals exactly for all nine specialty-years. Source: CMS QPP public use file via Mimilabs, SQL5.

When the gap opened, 2019–2024 (Figure 2)

From 2019 through 2021, chiropractic, physical therapy and podiatry all averaged positive adjustments (Figure 2). Chiropractic and podiatry turned negative in 2022, the first year the performance threshold reached 75 points, and stayed negative through 2024. Physical therapy’s average rose to +2.825% in 2022, the last year of the exceptional-performance bonus, then fell to +0.691% and +0.186%. These changes coincide with program rule changes, but the data cannot separate the effect of rules from changes in which clinicians appear in the file.

Category scores and reweighting (Figure 3)

In 2024 (Figure 3), chiropractic’s average final score (69.94) was 14th of the 15 specialties, ahead of only podiatry (67.39). Its quality average (51.73) and improvement activities average (28.12 of 40) were also 14th, each ahead of only podiatry. Its interoperability average (58.81) was 10th, above physical therapy (48.75) and podiatry (35.29), and its cost average (62.61) was third highest. Of the four categories, the largest gaps with physical therapy were in quality (22.4 points) and improvement activities (9.6 of 40 points). These category averages do not show how much each category moved the final score, for the reasons given below.

In 2023, chiropractic’s average quality score (51.62) was third lowest of the 15 specialties, ahead of pain medicine (51.41) and podiatry (39.26); physical therapy had the highest (77.15) (Table 8). Average cost scores rose for every specialty in 2024 (from 33.7 to 52.6 averaged across the 15), which coincides with a change CMS made to cost scoring for performance year 2024; cost scores should not be compared across those two years. Category averages cannot be added together to rebuild the final score, because category weights differ by year and clinician, some categories are reweighted to zero, and each average covers only records with a score.

Most records in all three specialties had Promoting Interoperability automatically reweighted because of special status or clinician type (chiropractic 68.0% in 2023, physical therapy 72.5%, podiatry 75.2%). The physical therapy hardship-exception share rose from 1.1% in 2023 to 27.4% in 2024, the largest change in any flag; 2024 was the first year CMS no longer automatically reweighted physical therapists as a clinician type. Its causes and effects were not examined further.

Table 8. Category scores and selected flags, 2023 and 2024

PI = Promoting Interoperability. Flags are percentages of records and can overlap. Full 15-specialty values are in the source extracts. Source: CMS via Mimilabs, SQL1 and SQL2.

Certified EHRs and the interoperability category explain little of the penalty

A clinician who is not reweighted and has no certified EHR scores zero on a category worth 25% of the final score, which caps the score at 75, the threshold itself. This mechanism is real but affected very few chiropractic records (Table 9). In 2023, 12 records (3.4%) reported, were not reweighted and scored zero on interoperability; they averaged a final score of 38.2 and an adjustment of −4.47%, and together account for −0.15 points of the −1.74% chiropractic average. The 77 nonreporting records account for −1.63 points. All 77 were reweighted for interoperability and all were small practices: their cut came from submitting no quality or improvement-activity data, not from the interoperability category. The at-risk group was 21 records (5.7%) in 2022 and 5 (1.5%) in 2024.

Within non-reweighted reporters, having a certified EHR identifier made little difference: −0.80% with an identifier and −0.71% without in 2023, and −0.91% and +0.60% in 2024. Many clinicians without an identifier report interoperability through a group, so the identifier is better read as a reporting marker than as a measure of technology use. Among reweighted chiropractic reporters, those with a certified EHR identifier were mostly hospital-based (65%) and those without one mostly small practices (50%). Physical therapy and podiatry show the same pattern at similar or larger scale (2023: 341 physical therapy records averaging −0.62%; 238 podiatry records averaging −1.50%).

Table 9. What makes up the chiropractic average payment adjustment, 2023

Contribution = sum of the group’s adjustments divided by all 353 records. Unrounded contributions (−1.632, −0.152, −0.095 and +0.141 points) sum to the published average of −1.738. The 68.0% reweighted in total matches SQL2. Source: CMS QPP public use file via Mimilabs, SQL7c and SQL9 (Author-run).

Certified EHR use among chiropractors who are in MIPS is not unusual (Table 10). In 2023, 177 of the 349 chiropractors in the MIPS data (50.7%) reported a certified EHR identifier, seventh of the 15 specialties, ahead of physical therapy (24.2%) and podiatry (28.1%) and level with internal and family medicine. The 2024 share was 52.9%.

Table 10. Clinicians in the MIPS data reporting a certified EHR identifier, 2023

Distinct NPIs. The certified-EHR counts equal those reported in The Digital Outlier (ARETE-OR-2026-007) for 2023, and the MIPS counts equal SQL3. Source: CMS QPP public use file via Mimilabs, SQL7b (Author-run).

Discussion

What the data show

Two facts define the MIPS picture for chiropractic. First, the program reaches very few chiropractors who bill Original Medicare: about 1 in 100 in 2023 and 2024, against at least 1 in 5 for every comparator specialty. Second, the chiropractors it does reach averaged lower scores and payment cuts from 2022 onward, a pattern shared only with podiatry. The first fact means the second describes a small group. That group also changed after 2021, shifting toward larger and hospital-based practices, so it is unlikely to represent the typical independent chiropractic office.

Why do so few chiropractors appear?

Low billing volume is part of the answer. Nearly all chiropractors billing Original Medicare fall below at least one minimum-volume test, and their median allowed charges ($13,305 in 2024) are less than one-sixth of the $90,000 test. Medicare’s chiropractic benefit covers only spinal manipulation, which limits how much a chiropractor can bill Medicare.

But volume is not the whole answer. Clinical social workers, clinical psychologists and physical therapists are just as likely to fall below the tests, and MIPS still reaches a fifth or more of them. Most of their MIPS records are group or APM participants, and most physical therapists belong to Medicare-enrolled groups of 16 or more. Most chiropractors belong to no group at all (63.7%), and those who do are in groups with a median of three clinicians, which are unlikely to clear the volume tests together. This matches Arete’s earlier finding in The Organizational Outlier: among Medicare-enrolled (PECOS-active) chiropractors, 80.9% of affiliation records were with organizations of five or fewer practitioners, 73.6% with single-specialty organizations of that size, and 58.2% with single-specialty organizations of one or two, while only 4.0% of multi-specialty organizations with 11 or more practitioners included a chiropractor. Enrollment and participation data now support an organizational explanation directly at the specialty level: chiropractors appear to stand outside MIPS largely because they practice alone or in very small groups, where low individual volume decides eligibility, while comparable professions are brought in by large groups. The files are not linked clinician by clinician, so no individual’s route into or out of MIPS is observed.

Who is in the file, and what their scores mean

When clinicians participate as a group, they receive the group’s score. The chiropractors who do appear in MIPS are therefore partly a reflection of the organizations they work in. After 2021, chiropractic records shifted toward hospital-based status and larger attributed patient counts, while the ratio of chiropractors in MIPS to those exceeding the tests on their own fell from about 4.4 in 2019 to about 1.8 in 2022 and 2023 (about 2.1 in 2024). Together these suggest that fewer chiropractors entered through small or mid-sized group practices after 2021; participation option was queried only for 2023 and 2024, so this cannot be tested directly. In those years most chiropractic MIPS records were group participants (67.1% and 61.5%), with 23.8% and 28.1% individual and the rest APM entities. One question for future work: across the 15 specialties, those with the highest shares of individually participating MIPS records were the ones with negative average adjustments in 2023 and 2024 (Table 4 and Table 6). Whether individual participation itself is associated with lower adjustments, or simply travels with nonreporting and practice size, would need a record-level comparison that is beyond the scope of this paper.

Nonreporting explains most of the chiropractic penalty. Records that submitted no data averaged cuts of about 5% to 7.5%; records that reported averaged close to zero. The chiropractic average is therefore mainly a reporting problem rather than a performance problem, although chiropractors who reported still scored somewhat lower than physical therapy and podiatry reporters. These data cannot show why records were nonreporting: some clinicians may not have known they were required to report, and some may have been covered by a group that did not report.

What this means in practice

• For anyone citing MIPS results by specialty (payers, analysts, associations, journalists): state how much of the specialty the results cover. For chiropractic, MIPS averages describe about 1% of chiropractors billing Original Medicare.

• For chiropractic practices: most chiropractors are below MIPS’s volume tests and receive no adjustment. For those who are eligible, alone or through a group, submitting data is what separates an average near zero from an average cut of 5% or more. Checking eligibility status each year is a low-cost step; Appendix A sets out a checklist.

• For small practices that are eligible: in 2023 every chiropractic nonreporting record was a small practice, and the interoperability category was already reweighted for all of them. Submitting quality and improvement-activity data, not buying a certified EHR, is what separated a near-zero average from a cut of about 7.5%.

• For practices considering group or network arrangements: billing under a larger practice’s tax ID can bring chiropractors into MIPS scoring, with its reporting obligations and possible adjustments, even when their own volume is low.

• For policy discussions: chiropractic’s negative MIPS averages should not be read as a measure of the profession’s quality of care. They describe a small, changing subset scored under rules that tightened sharply in 2022, and mostly reflect records that submitted no data.

Relationship to The Digital Outlier

The Digital Outlier (ARETE-OR-2026-007) found that only 0.53% of chiropractors billing Original Medicare appeared in certified-health-IT reporting in 2023. Its counts match the certified EHR identifiers in the MIPS file used here (for example, 177 chiropractors, 4,638 physical therapists and 16,253 internists in 2023), which suggests that its source is built from the same MIPS interoperability reporting. If so, a chiropractor outside MIPS cannot appear in it, and its 0.53% is bounded by MIPS’s 1.05% reach. Among chiropractors who are in MIPS, about half reported a certified EHR, a typical share. The digital gap that paper describes appears to be largely the same reach gap described here, and missing interoperability credit explains little of the chiropractic payment penalty. This does not show how many chiropractors use an EHR outside Medicare reporting, certified or not.

Relationship to A Decade of Divergence and The Denial Paradox

A Decade of Divergence described what Original Medicare paid for chiropractic and physical therapy services from 2013 to 2024, and The Denial Paradox described what was submitted and denied from 2015 to 2023. This paper adds the quality-program layer for 2017 to 2024. The three use different CMS files with different inclusion rules, so their counts are not directly comparable.

Key Limitations

• The MIPS public file covers clinician–practice combinations assigned a MIPS score and excludes those with fewer than 11 patients. It does not include clinicians excluded from MIPS, and its exact inclusion rules for voluntary reporters were not independently confirmed.

• The comparison population is not limited to MIPS-eligible clinicians, and the two files are not linked clinician by clinician. The share of Medicare-billing clinicians in the MIPS data is therefore not a participation rate.

• The minimum-volume estimate applies the tests to each chiropractor’s annual billing totals, not to CMS’s TIN/NPI determination periods or to groups, and the billing file omits clinicians with fewer than 11 beneficiaries. It is an approximation for every specialty, and the ratio of clinicians in MIPS to those exceeding the tests compares two different files that are not linked clinician by clinician; the route by which each clinician entered MIPS is inferred, not observed.

• The certified EHR identifier marks reporting through certified technology, not EHR use; clinicians reporting through a group may lack an individual identifier. SQL7a and SQL7b results were supplied as summaries, not extract files, and are reconciled against the published totals.

• The split by reporting status (SQL5) and the interoperability breakdowns (SQL7–SQL9) cover only the specialties and years queried.

• Group membership comes from a different file (the Doctors and Clinicians file, December 2023) that uses self-reported primary specialty, includes enrolled clinicians who did not bill, and records PECOS groups rather than the tax IDs CMS uses for MIPS eligibility. It is a single snapshot, and it is not linked to the MIPS or billing files clinician by clinician.

• All values are averages or percentages across records. No distributions, medians or confidence intervals were available, and no average is weighted by Medicare payments, so the averages do not show any clinician’s adjustment or any practice’s dollar impact.

• Patient counts, allowed charges and special statuses are attributed by participation option. For clinicians scored as part of a group or APM entity they describe the organization, not the individual.

• Category score averages exclude records without a score in that category, and category weights and reweighting vary by year and clinician. Category averages cannot be combined into the final score.

• Program rules (eligible clinician types, low-volume threshold, performance threshold, category weights, cost scoring, exceptions) changed during 2017–2024. Year-to-year changes mix program rules with changes in who appears in the file.

• The 2017 file flags every record as nonreporting and used a lower eligibility threshold; 2017 is shown for completeness but is not comparable with later years.

• Specialty is the label in each file. A clinician’s specialty can differ between files or between practices, and the specialty crosswalk between the two files has not been checked at the clinician level.

• The analysis is descriptive. Differences in case mix, practice size, reporting method, payer mix and organizational setting are not adjusted for, and no finding is causal.

Disclosures and Publication Status

This work is classified as a public-data reimbursement and quality-program analysis under the Arete Research Library Governance Framework (§2); it is not PBRN-sponsored human-subjects research. This analysis was produced by Arete Healthcare without external funding; Arete supports independent outpatient chiropractic and physical therapy practices and has a commercial and professional interest in Medicare payment, quality reporting, and payer policy affecting those practices. AI tools assisted with data review, calculation, and drafting. Every factual assertion and calculation requires responsible human verification before publication, and AI reconciliation does not substitute for the named Independent Data/Methodology Reviewer or DAWG approval.

AI use disclosure. Drafts before this version (labelled v1.0–v1.3) were prepared in October 2026 with assistance from ChatGPT (OpenAI; GPT-5.6 Sol, the same version used for this series’ other Original Research papers). Pipeline versions 1.0 to 1.22 (October 21–26, 2026) were built in the standard Original Research format with assistance from Claude (Anthropic; Claude Opus 5.5), which independently recomputed or reconciled every statistic against the source extracts and checked every plotted value against source data. An external review of version 1.6 by ChatGPT informed the wording of the organizational explanation. The supplementary queries SQL4–SQL11 were run by the Author. Figures 1–4 were produced by the Author without AI assistance; Figure 5 was drawn by the Author from a content specification (structure, labels and numbers) drafted with Claude’s assistance. Appendix A was drafted by the Author at DAWG’s suggestion and revised with Claude’s assistance. Arete’s Take was written by the Author; wording changes proposed by Claude were reviewed and accepted by the Author. All SQL queries were drafted by Mimibot, the AI assistant in Mimilabs, and run by the Author in Mimilabs. The Author takes responsibility for the accuracy of the content. Details are kept in the internal AI Assistance and Reproducibility Record maintained under the Arete Research Library Governance Framework.

Data. Aggregated public CMS data only. No patient-identifiable information was used.

Review status. Approved for release on October 26, 2026. Two non-conflicted DAWG reviewers approved the findings, methods and results, and at least two of the three Arete Executive Reviewers approved Arete’s Take, which was written by the Author, independent of DAWG (Governance Framework §1.3/§7).

Recommended Citation: Elton, D. The MIPS Divide. Arete Original Research ARETE-OR-2026-014, Version 2.1. Arete Healthcare LLC. Published October 26, 2026. https://arete.healthcare/research/the-mips-divide https://doi.org/10.13140/RG.2.2.22597.61923

References

• Centers for Medicare & Medicaid Services. Quality Payment Program: Participation and Performance Data (public use files). https://qpp.cms.gov/resources/performance-data

• Centers for Medicare & Medicaid Services. 2023 QPP Public Use File: Data Dictionary. https://data.cms.gov/sites/default/files/2025-06/3e246dab-33a2-4c25-8c7e-f6134a0fcdff/2023-QPP-PUF-Data-Dictionary.pdf

• Centers for Medicare & Medicaid Services. 2024 QPP Public Use File: Data Dictionary. https://data.cms.gov/sites/default/files/2026-06/d91f4a87-d921-4292-97e3-45c515e73af3/2024-QPP-PUF-Data-Dictionary.pdf

• Centers for Medicare & Medicaid Services. Medicare Physician & Other Practitioners – by Provider. data.cms.gov (accessed through Mimilabs table mimi_ws_1.datacmsgov.mupphy_prvdr).

• 42 CFR § 414.1405, Payment (MIPS performance thresholds, applicable percent, and additional performance threshold). https://www.law.cornell.edu/cfr/text/42/414.1405

• Centers for Medicare & Medicaid Services. Quality Payment Program Year 2 Notice of Proposed Rulemaking overview (Year 1 and proposed Year 2 low-volume thresholds), June 2017. https://www.cms.gov/files/document/quality-payment-program-nprm-year-2-final-2017-06-27-remediatedpdf

• Centers for Medicare & Medicaid Services. Quality Payment Program Year 3 Final Rule Overview (2019 clinician types and low-volume threshold). https://www.cms.gov/files/document/qpp-year-3-final-rule-overview-webinar-slidespdf

• American Academy of Ophthalmology. MIPS 2022: Who Does (and Doesn’t) Take Part in MIPS (secondary source for 2022 clinician types). https://www.aao.org/eyenet/article/mips-2022-who-does-doesn-t-take-part-in-mips

• American Academy of Ophthalmology. CMS Finalizes Major Changes to MIPS Cost Performance Category, November 2024 (secondary source for the 2024 cost scoring change). https://www.aao.org/advocacy/news/cms-finalizes-major-changes-mips-cost-performance-category

• American Chiropractic Association. Comments on the MIPS and APM proposed rule, June 27, 2016 (chiropractors included as MIPS eligible clinicians from the start). https://www.acatoday.org/wp-content/uploads/2021/10/06.27.16_ACA_Comments_MIPS-APM_NPRM_FINAL.pdf

• Mimilabs. Mirrored tables mimi_ws_1.datacmsgov.qpp and mimi_ws_1.datacmsgov.mupphy_prvdr; queries SQL1–SQL5 and SQL7–SQL11, extracted October 2026 (SQL4 onward run by the Author on October 21–22, 2026); query text is reproduced in the internal master document. The Doctors and Clinicians file was accessed through mimi_ws_1.provdatacatalog.dac_ndf.

• Arete Healthcare. The Organizational Outlier: Group Size, Specialty Composition, and Multi-Specialty Scaling of Chiropractic Compared to Fourteen Professions and Specialties. Arete Original Research ARETE-OR-2026-001, Version 3.14; August 19, 2026. https://doi.org/10.13140/RG.2.2.13222.28484

• Arete Healthcare. The Digital Outlier: Certified Health IT Reporting, EHR Platforms, and Products Across Fifteen Specialties. Arete Original Research ARETE-OR-2026-007, Version 1.1; September 2026. https://doi.org/10.13140/RG.2.2.23917.76001

• Centers for Medicare & Medicaid Services. Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule: Quality Payment Program policies fact sheet (Promoting Interoperability automatic reweighting, 2023 and 2024 performance periods). https://www.cms.gov/files/document/2024qpppoliciesfinalrulefactsheet.pdf

• Khullar D, Bond AM, O’Donnell EM, Qian Y, Gans DN, Casalino LP. Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study. JAMA Health Forum. 2021;2(5):e210527. https://doi.org/10.1001/jamahealthforum.2021.0527

• mdinteractive. 2024 Changes to Traditional MIPS (2024 category weights, performance threshold and adjustment scale; Figure 5). https://mdinteractive.com/node/3227

• mdinteractive. 2026 MIPS Rules (low-volume threshold, quality and improvement activities requirements, small-practice reweighting; Appendix A). https://mdinteractive.com/2026-mips-rules

• College of American Pathologists. 2025 vs. 2026 MIPS Comparison (data completeness, performance threshold, maximum adjustment; Appendix A). https://documents.cap.org/documents/2025-2026-mips-comparison.pdf

• College of American Pathologists. 2026 MIPS Claims-Based Reporting Fact Sheet (claims reporting for small practices; Appendix A). https://documents.cap.org/documents/2026-mips-claims-based-reporting-fact-sheet.pdf

• Society for Post-Acute and Long-Term Care Medicine (PALTmed). 2026 MIPS Payment Adjustment Information Released by CMS (adjustment applied to the Medicare paid amount for covered professional services; Appendix A). https://paltmed.org/news-media/2026-mips-payment-adjustment-information-released-cms

• American Podiatric Medical Association. 2025 MIPS Performance Year Reporting Is Open (submission window; Appendix A). https://www.apma.org/about-apma/news/news-releases/2026/2025-mips-performance-year-reporting-is-open/

• Centers for Medicare & Medicaid Services. MIPS 2020 Performance Period Virtual Group Participation Fact Sheet (virtual group composition and opt-in; Appendix A; current rules to be confirmed). https://www.plasticsurgery.org/documents/Health-Policy/MACRA/MIPS-2020-Performance-Period-Virtual-Group-Participation-Fact-Sheet.pdf

• Centers for Medicare & Medicaid Services. Quality Payment Program: Participation Status Lookup, reporting requirements and timeline. https://qpp.cms.gov

• Centers for Medicare & Medicaid Services. Doctors and Clinicians National Downloadable File, December 2023 release. Provider Data Catalog (accessed through Mimilabs table mimi_ws_1.provdatacatalog.dac_ndf).

• Elton, D. A Decade of Divergence. Arete Original Research ARETE-OR-2026-004, Version 15.1. Arete Healthcare LLC; October 19, 2026. https://arete.healthcare/research/a-decade-of-divergence https://doi.org/10.13140/RG.2.2.29102.88646

• Elton, D. The Denial Paradox. Arete Original Research ARETE-OR-2026-013, Version 2.1. Arete Healthcare LLC; October 23, 2026. https://arete.healthcare/research/the-denial-paradox https://doi.org/10.13140/RG.2.2.30472.58881

Glossary

Terms used in this paper, in plain language.

Appendix A. MIPS Practice Checklist for Chiropractic Practices

A practical guide to eligibility, reporting and financial impact, for performance year 2026. MIPS rules, thresholds and dates change every year; check each item against current CMS Quality Payment Program (QPP) guidance. This checklist is general information, not legal, billing or financial advice.

MIPS can raise or lower future Medicare Part B payments based on a clinician’s score. Most chiropractors do not individually exceed the MIPS minimum-volume tests, but some become subject to MIPS individually, through a group, by joining a virtual group, or by choosing to opt in. The checklist answers three questions: Am I subject to MIPS? What must I report, and when? Do the payment consequences justify the cost of reporting?

Most chiropractors can stop at Step 1. In 2024, an estimated 99.5% of chiropractors billing Original Medicare were at or below at least one MIPS minimum-volume test on their own billing, and only about 1 in 100 appeared in the MIPS data (Figure 1; Table 3). Steps 2 and 3 matter mainly for chiropractors who bill under a group that is subject to MIPS, or who choose to opt in.

Step 1. Determine MIPS eligibility

Start with CMS’s official determination, not an estimate from annual billing. Enter each clinician’s 10-digit NPI in the QPP Participation Status Lookup at qpp.cms.gov, select the performance year, and review the clinician’s status under every tax ID (TIN) through which Medicare services are billed.

Table A1. MIPS individual minimum-volume tests, 2026

A clinician must exceed all three tests, in both segments of CMS’s determination period, to be required to participate. CMS applies the tests to each clinician–practice (TIN/NPI) combination and, for group reporting, to the practice as a whole. Annual totals help anticipate eligibility but do not replace CMS’s determination. Sources: mdinteractive, 2026 MIPS rules; CMS QPP.

Eligibility checklist:

☐ Look up each clinician’s MIPS status for the performance year.

☐ List every TIN/NPI combination under which each clinician bills Medicare.

☐ Determine whether the clinician is individually required to participate.

☐ Check whether the practice is eligible at the group level and whether group reporting will apply.

☐ Review any Advanced Alternative Payment Model participation, exclusions or special statuses (for example, small practice: 15 or fewer clinicians).

☐ If the clinician exceeds one or two tests but not all three, decide whether opting in, or joining a virtual group (solo practitioners and groups of 10 or fewer clinicians combining for MIPS), is worthwhile. Either choice exposes the clinician to negative as well as positive adjustments, and a virtual group must be elected before the performance year begins; confirm current rules with CMS.

☐ Confirm final eligibility when CMS publishes its reconciled determination, and keep a dated copy.

Decision. Record each clinician’s status as individually required, participating through a group, virtual group, opted in, reporting voluntarily, or exempt. Clinicians excluded from MIPS generally receive no MIPS adjustment. Voluntary reporting by an excluded clinician does not create an adjustment; opting in does.

Step 2. Identify reporting requirements

Requirements depend on the reporting pathway, special statuses and category reweighting. Small practices have several simplifications that matter for chiropractic offices without a certified EHR.

Table A2. Traditional MIPS reporting categories, 2026

The performance threshold is 75 points, and the maximum adjustment is ±9%. Automatic Promoting Interoperability reweighting does not remove quality or improvement activities obligations. A small practice should confirm its status before buying certified-EHR capability solely for MIPS. Sources: mdinteractive, 2026 MIPS rules; College of American Pathologists (CAP), 2025–2026 MIPS comparison and 2026 claims-based reporting fact sheet.

Reporting readiness checklist:

☐ Identify the reporting pathway: individual, group, virtual group, MIPS Value Pathway, or APM.

☐ Confirm which categories apply and which are reweighted.

☐ Choose quality measures and the collection method (claims, registry or EHR), and confirm enough eligible cases can be captured.

☐ Choose and document the improvement activities, with start dates that allow 90 continuous days.

☐ Confirm that the EHR, registry or billing workflow supports data collection and submission.

☐ Name the person responsible for checking data and submitting it.

☐ Confirm the submission was accepted and keep the confirmation.

Table A3. Key dates, performance year 2026

Dates change each year; check the QPP timeline. Source: CMS QPP; APMA, 2025 performance year reporting announcement (submission window pattern).

Step 3. Weigh payments against reporting costs

For a required participant, the question is whether reporting costs less than the cut for not reporting. For a clinician who could opt in, it is whether possible positive adjustments justify the cost and the exposure to negative ones. MIPS adjustments apply to the Medicare-paid amount for covered professional services in the payment year, not to allowed charges (which include the patient’s 20% coinsurance), Medicare Advantage revenue or total practice revenue.

Table A4. Worksheet: Medicare payments exposed to adjustment

Table A5. Worksheet: annual MIPS reporting costs

Include only costs that are reasonably attributable to MIPS reporting.

Illustration. In 2024, chiropractic MIPS records that reported averaged −0.109% and records that did not report averaged −4.984%, a difference of 4.875 percentage points (Table 7; Figure 4). A clinician who submits nothing can receive up to the maximum −9%, a difference of 8.891 points from the reporters’ average. Table A6 applies both differences to three payment levels.

Table A6. Illustrative payment difference between reporting and not reporting

Sensitivity calculations, not forecasts. The reporting and nonreporting groups may differ in many ways, reporting does not guarantee a score, and positive adjustments depend on budget-neutrality scaling. For scale, half of chiropractors billing Original Medicare had allowed charges below $13,305 in 2024, and the paid amount is lower than allowed charges.

Reporting costs vary widely. A national study of physician practices estimated MIPS participation costs at $12,811 per physician per year in 2019 (interquartile range $2,861 to $17,715) and 201.7 hours of physician and staff time (Khullar et al., 2021). At $50,000 in paid amounts, reporting would pay for itself at a cost near the study’s 25th percentile (about $2,900) if the alternative were the maximum cut, but not at its mean. A small chiropractic office reporting a few claims-based measures may spend less than the physician practices studied; the worksheet in Table A5 is the better guide.

Final decision checklist:

☐ The practice’s reporting obligation is confirmed.

☐ The Medicare-paid amount subject to adjustment has been estimated.

☐ Reporting costs have been estimated.

☐ Unfavorable, expected and favorable scenarios have been compared, including the maximum cut.

☐ Any opt-in or virtual group decision has been assessed separately from mandatory reporting.

☐ The decision, responsible person and next review date are documented.

Table A7. Practice decision record

Practical takeaway. For most chiropractors, the first and often last step is confirming that MIPS does not apply. For practices that must report, the priority is a reliable reporting process, using small-practice options such as claims-based quality reporting where they fit, and a clear view of what not reporting would cost. Sources for this appendix are listed in References.

Related Arete research

• A Decade of Divergence
• The Denial Paradox
• Arete Research & Analytics: all Original Research and Analytic Briefs