Navigate the latest MIPS and QPP Proposed Rule: A Comprehensive Overview for CY 2026

July 14, 2025

The Centers for Medicare and Medicaid Services (CMS) has officially released the 2026 Quality Payment Program (QPP) proposed rule. The 1,803-page proposed rule contained many changes that may take place in the 2026 MIPS performance year and beyond.

This blog post breaks down the proposed changes to the QPP and MIPS for 2026. Check out our 2026 Top Proposed Changes Report for an overview of changes by MIPS category and a list of Quality measure changes.

Performance Threshold

CMS is proposing to maintain the current threshold to avoid a penalty at 75 points in 2026.

Category Weights

CMS is not proposing changes to performance category weights in 2026.

Quality Category

Measure Scoring

CMS is proposing that for the 2026 performance year, 19 measures receive the previously defined topped out measure benchmarks (see Table below). This scoring method applies to measures that belong to specialty sets with limited measure choice and a high proportion of topped out measures.

Click on the dropdown to see the quality measures that will be scored using the defined topped out measure benchmarks.

Measures Scored Using Topped Out Measure Benchmarks

Quality Measures Scored Using Defined Topped Out Measure Benchmarks

The following measures will be scored using the defined topped out measure benchmarks:

141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care (Medicare Part B Claims)
143: Oncology: Medical and Radiation – Pain Intensity Quantified (eCQM, MIPS CQM)
144: Oncology: Medical and Radiation – Plan of Care for Pain (MIPS CQM)
249: Barrett’s Esophagus (Medicare Part B Claims, MIPS CQM)
250: Radical Prostatectomy Pathology Reporting (Medicare Part B Claims, MIPS CQM)
320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (Medicare Part B Claims)
350: Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy (MIPS CQM)
351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation (MIPS CQM)
360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies (MIPS CQM)
364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines (MIPS CQM)
395: Lung Cancer Reporting (Biopsy/Cytology Specimens) (Medicare Part B Claims, MIPS CQM)
396: Lung Cancer Reporting (Resection Specimens) (MIPS CQM)
397: Melanoma Reporting (Medicare Part B Claims, MIPS CQM)
405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions (MIPS CQM)
406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients (Medicare Part B Claims, MIPS CQM)
430: Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy (MIPS CQM)
440: Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician (MIPS CQM)
463: Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) (MIPS CQM)
477: Multimodal Pain Management (MIPS CQM)

The following measure scoring rules will remain in effect:

For large practices (>15 clinicians), remove the 3-point floor for measures meeting data completeness and case minimum. These measures would be scored on a 1-10 point scale instead of a 3-10 point scale.
For small practices, the 3-point floor will remain.

Bonuses

No change to the small practice bonus or the improvement score bonus.

Measures

CMS is proposing the following changes to the Quality measure inventory:

5 new proposed measures
10 measures proposed for removal
32 existing measures with proposed substantive changes

In the coming weeks, we will publish our analysis of these proposed quality measures changes for the specialties we serve.

Data Completeness Threshold

Proposal to maintain at 75% in performance years 2026 - 2028

Cost Category

Total Per Capita Cost (TPCC) Attribution

CMS is proposing a major change to the TPCC attribution methodology, which addresses long-standing concerns around the inappropriate attribution of cost responsibility to specialty groups employing advanced practice non-physician practitioners (NPs, PAs, and CCNSs). Under the proposed change, these practitioners would be excluded from TPCC attribution if all other clinicians in the group are excluded based on specialty. This is a significant win for specialty practices that have been unfairly penalized under the current approach.

Introduction of New Cost Measures

CMS is proposing a new policy for introducing cost measures into the MIPS program. Under this policy, new cost measures would go through a two-year testing period before being factored into performance scoring. This would allow time to evaluate and refine the measures before they impact clinician scores.

Cost Measure Inventory

CMS is not proposing any new cost measures or removals for the 2026 performance year.

Improvement Activities

Improvement Activities List

There are several proposed changes to the list of improvement activities (IAs), including:

3 proposed new IAs, including Patient Safety in Use of Artificial Intelligence (AI).
7 changes proposed to existing IAs (predominantly measure ID changes).
8 proposed removals, which are the same as the measures suspended in 2025:
- AHE_5: MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
- AHE_8: Create and Implement an Anti-Racism Plan
- AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
- AHE_11: Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients
- AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
- ERP_3: COVID-19 Clinical Data Reporting with or without Clinical Trial
- PM_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)
- PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B

Additionally, the rule outlined the IAs previously finalized for removal in 2026. These include IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop and IA_CC_2: Implementation of Improvements that Contribute to More Timely Communication of Test Results.

Improvement Activities Subcategories

CMS is proposing to eliminate the Achieving Health Equity subcategory and replace it with a new subcategory, Advancing Health and Wellness.

Promoting Interoperability (PI)

There are many changes proposed for the PI category. Unless otherwise specified, changes would take effect in 2026.

Electronic Case Reporting (eCR)

CMS is proposing to suppress the eCR measure for the 2025 performance year/2027 MIPS payment year. This measure would not be due to the CDC's temporary pause on onboarding new healthcare organizations and local public health agencies.

Security Risk Analysis (SRA)

CMS is proposing to add a second attestation component to this measure. Clinicians would be required to attest “Yes” not only to conducting an SRA, but also to implementing security measures to address identified vulnerabilities (already required under HIPAA).

SAFER Guide Attestation

CMS proposes to require the use of the new 2025 SAFER Guides (currently, only the 2016 Guides are required).

PI Bonus Measures

CMS is proposing another optional bonus measure to the PI inventory: Public Health Reporting Using TEFCA. To satisfy this measure, clinicians would need to attest to being in active engagement option 2 (validated data production) with a public health agency to transmit health information using TEFCA. Clinicians would still be able to earn a maximum of 5 bonus points across all optional PI bonus measures.

Query of PDMP Request for Information

While no changes have been proposed for this measure, CMS is seeking feedback on two areas:

Whether to change the Query of PDMP measure from an attestation ("Yes" or "No") to a performance-based measure (numerator/denominator).
Whether to expand the range of drugs included in the measure.

MIPS Value Pathways (MVPs)

CMS is proposing 6 new MVPs covering diagnostic radiology, interventional radiology, neuropsychology, pathology, podiatry, and vascular surgery.

In addition, CMS is proposing to modify the definition and determination of a multispecialty group. Instead of basing this on two-digit specialty codes, clinicians would self-report their specialty mix during MVP registration.

CMS is also proposing to exempt small multispecialty practices from the mandatory subgroup reporting requirement that was previously finalized for 2026.

Although CMS reiterated its intention to sunset traditional MIPS and transition to mandatory MVP participation, no proposal was included in the rule. Previously, CMS requested feedback on potentially requiring MVP participation as early as 2029. Anatomy IT will continue to advocate for MVP participation to remain optional.

Next Steps

Share this information with your colleagues.
Check out our Top 2026 Proposed MIPS Changes Report.
In the coming weeks, we will post an analysis of the Quality measure changes, and an analysis of the MVPs.
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