Coding and Billing

MIPS in 2026: How to Protect Medicare Reimbursement

Photo Credit: Getty Images

Important information to know about MIPS in 2026

By Peter Cass, OD

June 1, 2026

The Centers for Medicare & Medicaid Services (CMS) recently finalized updates to the Merit-based Incentive Payment System (MIPS) that largely emphasizes program stability, while continuing a gradual shift toward MIPS Value Pathways (MVPs). For optometrists, the good news is that the core structure of MIPS remains familiar, but the details still matter, especially as performance in 2026 will directly impact Medicare Part B reimbursement in 2028.

Program Stability Continues in 2026

CMS has again opted for continuity rather than big changes. Several key MIPS policies remain unchanged:

Performance threshold remains at 75 points
Maximum positive or negative payment adjustment remains ±9%
Three reporting pathways remain available:
- Traditional MIPS
- MIPS Value Pathways (MVPs)
- APM Performance Pathway (APP)

CMS has confirmed that the 75-point performance threshold will remain in effect through the 2028 performance year, providing predictability for optometrists participating in MIPS reporting.

Low-Volume Exemptions Still Protect Many Small Practices

Many optometry practices will continue to qualify for the low-volume threshold exemption, which excludes clinicians from mandatory MIPS participation if they meet any of the following criteria:

Less than $90,000 in Medicare Part B allowed charges
Fewer than 200 Medicare patients
Fewer than 200 Medicare Part B services

In addition, small practices (15 or fewer clinicians) may continue to:

Report quality measures via claims
Remain exempt from the Promoting Interoperability performance category requirements (if they meet certain criteria).

Quality Category: Measure Inventory Updates

While the Quality category still accounts for 30% of the final MIPS score, CMS finalized notable inventory changes for 2026:

5 new quality measures added
10 quality measures removed
30 measures substantively updated

For optometrists, CMS continues to maintain an Optometry Specialty Measure Set consisting of six commonly reported measures, including:

MIPS #117 – Diabetes: Eye Exam
MIPS #130 – Documentation of Current Medications in the Medical Record
MIPS #226 – Preventive Care and Screening: Tobacco Use – Screening and Cessation Intervention
MIPS #238 – Use of High-Risk Medications in Older Adults
MIPS #374 – Closing the Referral Loop: Receipt of Specialist Report
MIPS #019 – Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

MIPS Value Pathways (MVPs): A Growing Opportunity

Although MVP participation remains optional in 2026, CMS continues to signal that MVPs represent the future direction of MIPS.

For eye care providers, the Complete Ophthalmologic Care MVP is now fully available and offers several advantages:

Reduced quality reporting requirements (4 measures instead of 6)
Only one improvement activity required, regardless of practice size
Measures more closely aligned with ophthalmic and optometric care delivery

The American Optometric Association (AOA) has encouraged practices to evaluate the Complete Ophthalmologic Care MVP as a way to reduce administrative burden while remaining competitive for positive payment adjustments.

Improvement Activities and Cost Category Updates

For 2026, CMS finalized:

3 new improvement activities
7 modified activities
8 removed activities

The Cost category remains at 30% of the MIPS score, but CMS introduced a two-year informational-only feedback period for new cost measures. This allows clinicians to review cost performance data before those measures affect final scores, an important buffer for specialties like optometry that have historically had limited influence over cost attribution.

Financial Context: Medicare Fee Schedule and MIPS

Most optometrists saw a 2.5% increase under the 2026 Medicare Physician Fee Schedule due to last-minute congressional action. However, MIPS adjustments remain budget neutral, meaning bonuses are funded by penalties assessed to underperforming clinicians.

As a result, even modest MIPS penalties can negate fee schedule gains, and consistently scoring above 75 remains the best defense against reimbursement reduction.

Remember this

2026 is a year of stability, not complacency. The 75-point threshold remains the line between penalties and bonuses.

Optometry measure sets remain narrow, which makes accuracy essential. Remember that Complete Ophthalmologic Care MVPs may simplify reporting while improving alignment.

Decisions made in 2026 affect reimbursement in 2028.

CMS may be moving cautiously, but the direction is clear: greater emphasis on coordinated care, cost accountability and outcome-driven reporting. Optometrists who treat 2026 as a strategic planning year rather than “more of the same” can protect Medicare revenue and reduce reporting fatigue.

Read more from Dr. Peter Cass here.

Read more on The Aging Eye here.

Read more on coding and billing here.