A Practical Guide to Improving MIPS Performance in Pathology

Most specialties have dozens of quality measures to choose from when building a MIPS reporting strategy. Pathology does not. The CMS specialty measure set includes just 7 QPP quality measures, with another 6 QCDR measures available exclusively through the Pathologists Quality Registry. That limited pool means each measure has a significant impact on your overall score.

The structural challenge goes deeper than measure availability. Pathologists are typically classified as non-patient-facing clinicians, which triggers automatic reweighting of two MIPS performance categories. Promoting Interoperability drops to 0%, and Cost is rarely attributed to pathologists under CMS methodology. For large groups (16 or more clinicians), that reweighting pushes the Quality category to 85% of the final MIPS score. For small practices (15 or fewer), Quality and Improvement Activities split evenly at 50% each.

The practical effect: pathology groups have fewer measures to report and less flexibility to offset a low-scoring measure with stronger performance elsewhere. The performance threshold sits at 75 points, and the maximum negative payment adjustment for falling short is 9% of Medicare Part B reimbursement.

This guide covers the areas where pathology groups have the most control over their MIPS outcome: measure selection, data completeness, clinical documentation, improvement activities, and audit readiness. It draws on the operational patterns we see across pathology billing and reporting engagements where these issues surface most frequently.

The Pathology Measure Landscape🔗

QPP Quality Measures (CMS Specialty Set)🔗

Seven measures make up the CMS pathology specialty set:

• QPP 249: Barrett Esophagus Pathology Reporting
• QPP 250: Radical Prostatectomy Pathology Reporting
• QPP 395: Lung Cancer Reporting (biopsy and cytology specimens)
• QPP 396: Lung Cancer Reporting (resection specimens)
• QPP 397: Melanoma Reporting
• QPP 440: Skin Cancer: Biopsy Reporting Time — Pathologist to Clinician
• QPP 491: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in colorectal, endometrial, gastroesophageal, or small bowel carcinoma

MIPS requires reporting on 6 quality measures, including at least 1 outcome or high-priority measure. If a specialty set contains fewer than 6 measures, all measures in the set must be reported. With 7 available, pathology groups have minimal flexibility in measure selection.

QCDR Measures (Pathologists Quality Registry)🔗

Six additional measures are available through the Pathologists Quality Registry, a qualified clinical data registry operated by the College of American Pathologists:

• CAP 30: Urinary Bladder Cancer Complete Analysis and Timely Reporting
• CAP 34: Molecular Assessment Biomarkers for Non-Small Cell Lung Cancer
• CAP 40: Squamous Cell Skin Cancer Complete Reporting
• CAP 42: Barrett’s Esophagus Complete Analysis with Appropriate Consultation
• CAP 43: Complete Reporting of Gastrointestinal Metaplasia
• CAP 44: Molecular Assessment for Endometrial Carcinoma

These QCDR measures can only be reported through the Pathologists Quality Registry. They expand the available measure pool and may offer scoring advantages depending on benchmark distributions, but they require registry participation.

Reporting Method Matters🔗

Groups of 16 or more clinicians cannot submit quality measures through claims. Registry-based reporting is required for these larger groups, which adds an operational layer that smaller practices submitting via claims may not face.

CMS publishes benchmarks for each measure annually. Checking these benchmarks through the QPP Explore Measures tool before finalizing your measure selection helps identify where scoring potential is strongest based on national performance distributions.

Measure Selection Strategy🔗

With only 13 total measures available (7 QPP + 6 QCDR), pathology groups don’t have the luxury of picking and choosing from a broad menu. The decision comes down to which combination of measures your group can reliably perform well on, given your case mix, documentation workflows, and reporting infrastructure.

Start with the QPP measures that align with your highest-volume case types. A group that processes a high volume of lung cancer specimens will naturally have strong denominator counts for QPP 395 and 396, which supports both data completeness and benchmark scoring. A group with limited melanoma volume may struggle to meet the 20-case minimum for QPP 397, making it a less reliable scoring option.

QCDR measures can fill gaps, but they require participation in the Pathologists Quality Registry. For groups already using the registry, adding QCDR measures to the reporting strategy is operationally straightforward. For groups that aren’t, the decision to join should factor in the reporting advantages against the cost and setup time.

The goal is to submit 6 measures where your group can meet the 75% data completeness threshold and perform competitively against national benchmarks. Submitting additional measures beyond 6 is optional but can provide a scoring buffer if one measure underperforms.

Measures Removed for 2026🔗

Three long-standing QCDR measures are no longer available starting in the 2026 performance year: CAP 22 (Biopsy Reporting Time to Clinician), CAP 38 (Prostate Cancer Reporting: Complete Analysis), and CAP 41 (Basal Cell Skin Cancer: Complete Reporting). Groups that previously relied on these measures will need to adjust their reporting strategy.

Data Completeness: The 75% Threshold🔗

Data completeness is the percentage of eligible cases (denominator cases) for which a practice reports performance or exclusion data. CMS requires at least 75% data completeness for each reported measure, a threshold that holds through the 2028 performance year. Each measure also requires a minimum of 20 denominator-eligible cases to be scored against national benchmarks.

Falling below 75% on a measure limits its scoring potential. In a specialty where the Quality category can represent 85% of the final score, incomplete data on even one measure can meaningfully drag down overall performance.

Where Completeness Breaks Down🔗

The most common gaps stem from case identification and capture. MIPS-eligible cases are tied to specific CPT and ICD-10 code combinations, and if those cases aren’t flagged and routed into the reporting workflow, they never reach the data completeness denominator. In pathology, this often involves coordination between the billing system, the laboratory information system, and the reporting registry.

Other contributing factors include staff turnover that disrupts established workflows, inconsistent coding practices across pathologists within a group, and manual processes that depend on individual follow-through rather than system-level automation.

Timing matters as well. Data completeness is measured across the full 12-month performance period. Groups that discover completeness gaps late in the year have limited options for recovery. A measure sitting at 60% completeness in October may not reach 75% by December, especially if the underlying capture issue hasn’t been resolved.

Practical Steps🔗

Building reliable data completeness starts with automating the identification of MIPS-eligible cases. When case capture depends on manual review, gaps can accumulate over the performance year and may not be identified until it is difficult to correct them.

Validation checkpoints at regular intervals (monthly or quarterly) allow groups to catch completeness issues while there’s still time to address them. Assigning a specific person or team to own data completeness monitoring creates accountability that shared responsibility often lacks.

Documentation That Supports Numerator Criteria🔗

Measure performance in pathology depends on whether clinical documentation contains the specific elements that satisfy numerator criteria (the specific documentation required for a case to count toward performance). A pathologist may deliver care that meets the intent of a measure, but if the documentation doesn’t include the required reporting elements, the case scores as “performance not met.”

This disconnect between care delivery and documented performance is one of the more frustrating aspects of MIPS reporting for pathology groups. The fix is aligning documentation practices with measure specifications at the point of reporting, not after the fact.

What This Looks Like in Practice🔗

Each quality measure has defined numerator criteria: the specific data elements or actions that must be documented for a case to count as a performance hit. For pathology measures, these typically involve structured reporting elements: synoptic report completeness, biomarker testing documentation, reporting timeliness, and inclusion of specific diagnostic findings.

QPP 491 (MMR/MSI Biomarker Testing), for example, requires documented evidence that mismatch repair or microsatellite instability testing was ordered, performed, or that the patient met an exclusion criterion. If the pathology report doesn’t capture this in a way that maps to the measure specification, the case falls into the denominator without contributing to the numerator.

Building Documentation Into Workflow🔗

Training pathologists on which report elements feed MIPS measures is a necessary first step, but sustainable improvement comes from building those elements into reporting templates and workflows. Synoptic reporting protocols, standardized report templates, and documentation checklists tied to specific measure requirements reduce reliance on individual memory.

A pre-submission documentation review — checking a sample of cases against numerator criteria before data is finalized — catches systematic gaps while corrections are still possible.

The cost of getting this wrong compounds over the performance year. A documentation pattern that consistently misses a required element on one measure will produce a low numerator rate across hundreds of cases. Catching that pattern in Q1 is a training fix. Catching it in Q4 is a scoring problem with no remedy.

Improvement Activities for Pathology Groups🔗

Improvement Activities represent 15% of the final MIPS score for large pathology groups and 50% for small practices. Starting in 2025, all activities are equally weighted at 20 points each, eliminating the previous distinction between high-weight and medium-weight activities.

The reporting requirements are relatively straightforward: attest to completing 2 activities (or 1 for small and non-patient-facing practices) performed for a minimum of 90 continuous days during the performance year. For group reporting, at least 50% of the physicians in the practice must perform the same activity.

Attestation and Documentation🔗

Improvement Activities are reported through attestation, not detailed performance data. Practices confirm that they completed the activity; they do not need to submit supporting documentation at the time of attestation.

However, CMS can audit, and documentation must be retained for 10 years. That documentation should demonstrate that the activity was actually performed for the required duration and by the required number of clinicians in the group.

Attestation can be submitted through qualified registries like the Pathologists Quality Registry or directly through the CMS QPP portal. Most billing companies cannot submit improvement activity attestations on behalf of a practice, which means the reporting responsibility often falls to the practice itself.

Choosing the Right Activities🔗

With all activities now equally weighted, the selection decision comes down to which activities align with work the practice is already doing or could realistically implement within the performance year. Selecting activities that overlap with existing quality improvement efforts reduces the operational lift and makes documentation easier to maintain.

For pathology groups, activities related to participation in clinical data registries, quality improvement interventions, or peer-led case review often map well to existing workflows. Groups already participating in the Pathologists Quality Registry for quality measure reporting, for example, may be able to leverage that participation as documentation for a registry-based improvement activity.

The key is to make the selection early in the performance year. Because activities must be performed for 90 continuous days, a late start narrows the window. Groups that identify their activities in Q1 and assign ownership for documentation have a much easier time at attestation than those scrambling to assemble records in December.

The Small Practice Advantage🔗

For practices with 15 or fewer clinicians, improvement activities carry substantially more weight. At 50% of the final score, this category is just as important as quality measure performance. The upside is that small and non-patient-facing practices only need to complete 1 activity to earn full credit. This creates a significant scoring opportunity with relatively low effort, provided the practice completes the activity, documents it, and attests on time.

Audit Readiness and Pre-Submission Review🔗

CMS reserves the right to audit MIPS submissions after data has been accepted. In the event of an audit, practices need documentation that confirms the accuracy of their reported quality measure data and the completion of attested improvement activities.

Pre-Submission Review🔗

Reviewing measure performance data before final submission is one of the highest-value steps a pathology group can take. A quarterly review cadence — checking data completeness rates, numerator performance, and documentation alignment — surfaces problems while there’s still time to intervene.

This review should include: verification that all eligible cases are captured in the denominator, spot-checking documentation against numerator criteria for each reported measure, and confirming that improvement activity documentation is current and complete.

Post-Submission Audit Preparedness🔗

If CMS initiates an audit, the practice will need to produce records supporting its submission. For quality measures, that means access to the underlying case data and clinical documentation. For improvement activities, it means documentation showing the activity was performed for the required 90-day period by the required percentage of clinicians.

Establishing an internal review process and retaining organized documentation year-over-year reduces the risk of an audit finding discrepancies that result in score adjustments or penalties.

What’s Ahead: The Pathology MVP and 2026 Changes🔗

CMS continues to steer clinicians away from Traditional MIPS and toward MIPS Value Pathways (MVPs). A pathology-specific MVP has been finalized for the 2026 performance year, designed around diagnostic reporting, cancer protocols, and laboratory workflows. While the scoring methodology remains the same, MVPs bundle quality measures, improvement activities, and cost measures around a clinical theme.

Beyond the MVP, the 2026 performance year brings a few changes that affect pathology directly. Three QCDR measures (CAP 22, 38, and 41) are no longer available, narrowing an already limited measure pool. CMS has also introduced a 2.5% efficiency reduction to work RVUs for non-time-based services, which will affect reimbursement for some pathology services independent of MIPS performance.

The direction is clear: CMS expects more structured, data-driven quality reporting from pathology groups, not less. Practices that invest in their reporting infrastructure, documentation processes, and data completeness monitoring now will be better positioned as these changes take effect.

Next Steps🔗

MIPS performance in pathology comes down to a few controllable areas: selecting the right measures from a limited set, meeting the 75% data completeness threshold on each one, documenting the clinical elements that satisfy numerator criteria, completing and attesting to improvement activities, and maintaining audit-ready records.

Each of these areas represents an operational process, not a one-time fix. Groups that build these processes into their annual workflow — rather than treating MIPS as a year-end reporting exercise — are better positioned to protect their Medicare reimbursement and avoid preventable penalties.

Medusind has over 20 years of experience in pathology billing and revenue cycle management. Our team helps pathology groups navigate MIPS reporting requirements, optimize measure performance, and protect revenue. To evaluate your current MIPS reporting strategy, connect with our pathology billing team.

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