Navigate the Latest MIPS and QPP Final Rule: A Comprehensive Overview for CY 2026

October 31, 2025

The Centers for Medicare and Medicaid Services (CMS) has officially released the 2026 Quality Payment Program (QPP) final rule. The 2,375-page final rule contains many changes that will take place in the 2026 MIPS performance year and beyond.

This blog post breaks down the finalized changes to the QPP and MIPS for 2026.

Performance Threshold

CMS finalized maintaining 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

For the 2026 performance year, 19 measures will 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 finalized the following changes to the Quality measure inventory:

5 new measures
10 measure removals
30 existing measures with substantive changes

In the coming weeks, we will publish our 2026 Top Final Changes Report, which will include a list of Quality measure changes for the specialties we serve.

Data Completeness Threshold

Will remain at 75% in performance years 2026 - 2028

Cost Category

Total Per Capita Cost (TPCC) Attribution

CMS finalized 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). These practitioners will now 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 finalized a new policy for introducing cost measures into the MIPS program. Under this policy, new cost measures will go through a two-year testing period before being factored into performance scoring, which will allow time to evaluate and refine the measures before they impact clinician scores.

Cost Measure Inventory

There are no new cost measures or removals for the 2026 performance year.

Improvement Activities

Improvement Activities List

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

3 new IAs, including Patient Safety in Use of Artificial Intelligence (AI).
7 changes to existing IAs (predominantly measure ID changes).
8 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, there are IAs that were 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 finalized the proposal to eliminate the Achieving Health Equity subcategory and replace it with a new subcategory, Advancing Health and Wellness.

Promoting Interoperability (PI)

CMS finalized many changes for the PI category. Unless otherwise specified, changes will take effect in 2026.

Electronic Case Reporting (eCR)

CMS finalized the proposal to suppress the eCR measure for the 2025 performance year/2027 MIPS payment year, due to the CDC's temporary pause in onboarding new healthcare organizations and local public health agencies. CMS clarified that clinicians must still report the eCR measure (by attesting “Yes” or “No” or taking an exclusion), but they will receive the maximum points possible. If a clinician does not report the eCR measure, they will receive zero points for the Public Health and Clinical Data Exchange objective of the PI category.

Security Risk Analysis (SRA)

CMS finalized the proposal to add a second attestation component to this measure. Clinicians will now 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 will require the use of the new 2025 SAFER Guides in 2026 (currently, only the 2016 Guides are required).

PI Bonus Measures

CMS finalized another optional bonus measure to the PI inventory: Public Health Reporting Using TEFCA. To satisfy this measure, clinicians 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 will still be able to earn a maximum of 5 bonus points across all optional PI bonus measures.

MIPS Value Pathways (MVPs)

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

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

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

Although CMS reiterated their goal of eventually sunsetting traditional MIPS and transitioning to mandatory MVP participation, they stated that the date of this transition has not been determined and will be established through the official notice and comment rulemaking process. In the past, CMS has 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 back in the coming weeks for our Top 2026 Final MIPS Changes Report, where we will provide an overview of changes by MIPS category and a list of Quality measure changes.
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Written By: Sarrah Hakim, MHSA