Yes — but not always. MIPS eligibility for physical therapy practices depends on your Medicare billing volume, not your specialty alone. Since 2019, physical therapists have been recognized as MIPS-eligible clinicians under CMS's Quality Payment Program (QPP), meaning MIPS Medicare therapists are now subject to the same performance evaluation and payment adjustment framework that has applied to physicians for years. Whether your specific clinic is required to report, however, is determined by whether you exceed the CMS low-volume threshold — three specific Medicare billing criteria that CMS evaluates annually using your claims data.

This guide cuts through the ambiguity. If you are a PT clinic owner, practice administrator, or PT director trying to understand your obligations for the 2026 performance year, here is exactly what you need to know.

When PTs Must Report MIPS

Physical Therapists Must Report MIPS If They Meet All Three of the Following

• Bill Medicare Part B — specifically using the CMS-1500 claim form as a private practice provider (not via the UB-04 institutional billing form)
• Exceed the CMS low-volume threshold — more than $90,000 in Part B allowed charges, more than 200 Medicare beneficiaries, and more than 200 covered professional services
• Are not a Qualifying APM Participant — most outpatient PT clinics are not enrolled in an Advanced Alternative Payment Model, making MIPS the default track

If you meet all three conditions above, MIPS reporting is mandatory for your 2026 performance year. Missing the reporting deadline means an automatic maximum penalty on your 2028 Medicare payments.

What Is MIPS and Why Does It Apply to Physical Therapy?

Understanding why MIPS applies to therapy clinics at all requires a brief look at where it came from and what it was designed to do — without going into the full mechanics of scoring, which is covered in the complete MIPS guide for rehab therapy clinics.

MIPS Under the CMS Quality Payment Program

MIPS is one of two reporting tracks under the Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015. It replaced several older CMS reporting programs — including the Physician Quality Reporting System (PQRS) and the Value Modifier — consolidating them into a single performance-based framework. Under MIPS, CMS evaluates eligible clinicians across four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Your composite score determines a positive, neutral, or negative adjustment to your Medicare Part B reimbursements two years after the performance year.

The 2026 performance threshold remains at 75 points, consistent with CMS's finalized policy maintaining stability through the 2028 performance year. Scores below 75 points result in a negative payment adjustment. Scores at or above 75 result in neutral or positive adjustments, with higher scores qualifying for additional incentives where available.

Why Rehab Clinics Are Included

Physical therapists, occupational therapists, and speech-language pathologists in private practice were added to the list of MIPS-eligible clinician types beginning with the 2019 performance year. This expansion reflected CMS's recognition that outpatient therapy services represent a significant and growing portion of Medicare Part B expenditure — and that quality and cost accountability should extend to the full spectrum of Medicare-billing providers, not just physicians.

For outpatient PT clinics specifically, the Medicare Part B context is critical. Therapists who bill Medicare using the CMS-1500 form — the standard claim form for private practice — are eligible for MIPS. Therapists billing through the UB-04 form in institutional settings such as hospital outpatient departments are generally excluded. If you are a private outpatient rehab practice, CMS-1500 billing is your default, and MIPS eligibility applies.

Understanding MIPS Eligibility Requirements for Physical Therapy

MIPS eligibility for physical therapy clinics is not a judgment about the quality of care you provide. It is a purely administrative determination based on your Medicare billing volume during a specific 12-month lookback period. CMS reviews claims data from two snapshot windows prior to the performance year to determine whether each clinician or group exceeds the low-volume threshold.

The CMS Low-Volume Threshold Explained

The low-volume threshold consists of three distinct criteria. A physical therapist or practice must exceed all three to be required to participate in MIPS. Falling at or below any single criterion is sufficient for exclusion from mandatory participation.

CMS evaluates these criteria using Medicare claims data reviewed across two 12-month determination periods prior to the performance year. If you exceed all three thresholds across both review periods, MIPS participation is required. If you fall below any one of the three in either period, you are excluded from mandatory participation — though you may still choose to voluntarily opt in.

Important nuance: Eligibility is evaluated separately at both the individual clinician level (by NPI) and the group practice level (by TIN). A clinician who does not individually exceed the threshold may still be required to report if their group practice does — and group reporting covers all clinicians billing under that TIN, even those who would otherwise be exempt individually.

Individual vs. Group Eligibility

Solo PTs are evaluated entirely on their individual NPI. If your Medicare billing as a solo practitioner does not exceed all three low-volume threshold criteria, you are excluded from mandatory MIPS participation for that year.

Multi-provider therapy clinics are evaluated at both the individual and group level. Group eligibility is determined using the combined Medicare billing volume of all clinicians under the same Tax Identification Number (TIN). A clinic where no single therapist individually exceeds the threshold could still be required to report MIPS if the group collectively does.

Group TIN reporting is optional, not mandatory, even when the group is eligible. However, if a group practice elects to participate in MIPS at the group level, the submission must include data for all MIPS-eligible clinicians billing under that TIN — including those who may not qualify individually. This makes the decision to report as a group a meaningful one that requires buy-in across your clinical team.

Are Small Therapy Clinics Exempt?

This is one of the most common misconceptions among outpatient rehab practice owners: the assumption that a small clinic is automatically exempt from MIPS. In reality, the low-volume threshold is easier to exceed than most clinic owners expect.

Consider a two-therapist outpatient PT clinic seeing a steady mix of Medicare patients. At a typical Medicare allowed rate for evaluation and treatment CPT codes, billing $90,000 in Part B charges over 12 months is achievable with fewer than 10 Medicare patients per week. Seeing 200 unique Medicare beneficiaries — roughly four new Medicare patients per week throughout the year — is similarly within reach for a clinic that actively takes Medicare assignment.

Do not assume exemption. The only way to confirm your MIPS status for a given performance year is to check the CMS QPP Participation Status Tool using your NPI. Assuming you are exempt without verifying — and subsequently failing to report — results in the maximum negative payment adjustment. Verification takes less than five minutes and should be done at the start of every performance year.

Who Is Excluded from MIPS?

CMS does define clear exclusion categories for physical therapists and therapy clinics. Understanding these helps you confirm whether your practice genuinely sits outside mandatory MIPS participation — or whether you are at risk of assuming an exemption that does not apply.

Clinicians and Practices Excluded from Mandatory MIPS Participation

• Below the low-volume threshold — falling at or below any one of the three criteria (charges, beneficiaries, or services) during the CMS determination period
• Qualifying APM Participants (QPs) — clinicians who meet the patient or payment threshold for participation in a CMS Advanced Alternative Payment Model. Note: most outpatient PT practices do not currently meet QP status due to the limited APM structures available for private therapy practices
• Newly enrolled Medicare providers — clinicians in their first year of billing Medicare Part B are excluded from MIPS for that performance year. This grace period allows new providers to establish billing patterns before performance measurement begins
• Institutional billers — therapists billing via the UB-04 form in hospital outpatient or institutional settings are generally excluded from MIPS, as these services fall outside the Medicare Part B private practice framework

One important nuance regarding APM participation: the majority of physical, occupational, and speech therapy providers in private practice are not Qualifying APM Participants. Achieving QP status requires meeting specific patient volume or revenue thresholds within an Advanced APM structure — a bar that is difficult for smaller, independent outpatient therapy clinics to reach given the limited APM options available to the therapy specialty. For most PT clinics, MIPS is the operative track by default.

How to Check Your MIPS Eligibility Status

CMS provides a free, publicly accessible tool specifically for confirming your MIPS eligibility status. Checking it takes less than five minutes and should be a standard part of your January practice management routine at the start of every performance year.

Go to the CMS QPP Participation Status Tool- Navigate to qpp.cms.gov and click on "Check Participation Status" under the MIPS section of the site.

Enter your NPI- Search by your individual National Provider Identifier (NPI) to see your eligibility status as a solo clinician. For group-level eligibility, you can search by TIN after logging in with your HARP account credentials.

Review your eligibility result- The tool will confirm whether you are required to report MIPS individually, eligible to opt in, or excluded. It will also show your Advanced APM status and — importantly — preliminary eligibility information for future performance years.

Check each TIN separately- If you practice under more than one Tax Identification Number — for example, if you work across multiple clinic locations — you must check eligibility for each NPI/TIN combination independently. Eligibility is determined at the NPI and TIN level, not across your entire practice footprint.

Re-check after the final determination period- CMS issues a preliminary eligibility determination and then a final determination after the second snapshot period. Your status can change between the two. Always verify your final status before making any decision about whether to collect and submit MIPS data.

How Often Does MIPS Eligibility Change?

MIPS eligibility is redetermined every year. CMS does not carry forward your prior-year status — each performance year begins with a fresh evaluation of your Medicare billing data from the applicable determination period. This means a clinic that was excluded from MIPS in 2025 may be required to participate in 2026 if its Medicare volume grew. Conversely, a clinic that drops below the low-volume threshold due to a reduction in Medicare patient volume may become exempt in a year when it was previously required to report.

Several factors can shift your eligibility from one year to the next: adding new Medicare-billing therapists to your practice, expanding to a new clinic location, taking on a higher Medicare payer mix, or changes in the local referral patterns that affect how many Medicare beneficiaries you see. Practice growth, in particular, is a reliable path to crossing the low-volume threshold — and many clinic owners discover their MIPS obligation for the first time only after their practice has grown beyond a point where the threshold is clearly exceeded.

The practical implication is straightforward: eligibility checking is not a one-time event. It is an annual responsibility that should be built into your practice's January operations calendar, before the performance year is underway and before any decisions are made about whether to invest in quality data collection for that year.

Even if your clinic qualifies for MIPS participation, eligibility is only the first step. Understanding whether your documentation workflows, quality reporting processes, and billing practices are prepared to support strong MIPS performance is a separate — and equally important — question. A clinic that knows it is required to report but has no infrastructure to capture quality data throughout the year will find itself scrambling at year-end with incomplete data and a weaker score than its clinical performance actually warrants.

Frequently Asked Questions

Do physical therapists have to report MIPS every year?

Yes, if you are determined to be a MIPS-eligible clinician for a given performance year, reporting is required for that year. CMS redetermines eligibility annually based on your Medicare billing data. Your status can change year to year as your Medicare patient volume grows or contracts. Check your status each January at qpp.cms.gov using your NPI before making any decision about data collection for that performance year.

What is the low-volume threshold for MIPS in physical therapy?

The CMS low-volume threshold requires a physical therapist to exceed all three of the following to be required to participate: more than $90,000 in Medicare Part B allowed charges, more than 200 Medicare beneficiaries served, and more than 200 covered professional services provided under Medicare Part B. Falling at or below any single criterion qualifies your clinic for exclusion from mandatory MIPS participation for that year.

Are small therapy clinics exempt from MIPS?

Small therapy clinics may be exempt if they fall below the CMS low-volume threshold — but many clinic owners incorrectly assume exemption without verifying. A clinic seeing even a moderate volume of Medicare patients can exceed all three threshold criteria within a calendar year. The only way to confirm exemption is to check your NPI-level eligibility through the QPP Participation Status Tool. Do not assume; verify.

How do PTs check their MIPS eligibility?

Visit qpp.cms.gov and use the QPP Participation Status Tool. Enter your individual NPI to see whether you are required to report MIPS individually, eligible to opt in, or excluded for the current performance year. For multi-provider clinics, log in with a HARP account to check group-level eligibility by TIN. Check separately for each NPI/TIN combination if you bill under more than one practice.

What happens if I ignore MIPS reporting?

If you are a MIPS-eligible clinician and fail to submit any performance data, CMS automatically applies the maximum negative payment adjustment to your Medicare Part B reimbursements two years after the performance year. For 2026, the performance threshold is 75 points and the maximum negative adjustment is -9%. Non-reporting is the worst possible MIPS outcome — it is entirely preventable and represents a direct, unnecessary reduction in your Medicare revenue.

Does Medicare automatically enroll physical therapists in MIPS?

No. Medicare does not automatically enroll you in MIPS or send notifications that you are required to report. CMS determines eligibility from claims data, but the responsibility to check your status, collect quality data throughout the performance year, and submit before the annual deadline rests entirely with you or your practice administrator. Clinicians who miss the deadline receive the maximum penalty with no recourse.

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