A Practical Guide to Improving MIPS Performance in Radiology

Most specialties have dozens of quality measures to choose from when building a MIPS reporting strategy. Radiology does not. The CMS specialty measure set includes just 6 QPP quality measures, with additional QCDR measures available exclusively through the American College of Radiology’s National Radiology Data Registry (NRDR). That limited pool means each measure has a significant impact on your overall score.

The structural challenge goes deeper than measure availability. Many radiologists are classified as non-patient-facing clinicians, which triggers automatic reweighting of certain MIPS performance categories. Promoting Interoperability is commonly reweighted to 0%, and Cost attribution often remains limited depending on the radiologist’s role and billing structure under CMS methodology. For large groups (16 or more clinicians), that reweighting can push the Quality category to 85% of the final MIPS score. For small practices (15 or fewer), Quality and Improvement Activities may split evenly at 50% each.

The practical effect: radiology 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 radiology 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 radiology billing and reporting engagements where these issues surface most frequently.

The Radiology Measure Landscape🔗

QPP Quality Measures (CMS Specialty Set)🔗

The CMS Diagnostic Radiology specialty set currently includes 6 measures:

• QPP 145: Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy
• QPP 360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies
• QPP 364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules
• QPP 405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions
• QPP 406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules
• QPP 494: Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults

MIPS requires reporting on 6 quality measures, including at least 1 outcome or high-priority measure. Because the Diagnostic Radiology specialty set only contains 6 measures, groups reporting through the specialty set typically need to report all applicable measures.

QCDR Measures (ACR NRDR)🔗

Additional specialty-specific measures are available through the American College of Radiology’s National Radiology Data Registry (NRDR), a CMS-approved Qualified Clinical Data Registry (QCDR).

The NRDR supports multiple radiology-focused QCDR measures tied to registries such as:

• ·Dose Index Registry (DIR)
• ·General Radiology Improvement Database (GRID)
• ·Lung Cancer Screening Registry (LCSR)
• ·National Mammography Database (NMD)
• ·Interventional Radiology Registry
• ·CT Colonography Registry

These QCDR measures expand the available reporting pool and may provide scoring advantages depending on benchmark distributions, but they require registry participation through the ACR.

Reporting Method Matters🔗

Groups of 16 or more clinicians generally cannot rely on claims-only reporting for an effective MIPS strategy. Registry-based reporting is typically required for larger radiology groups, adding 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 a limited number of specialty-specific measures available, radiology groups do not have the luxury of choosing from a broad reporting menu. The decision comes down to which measures your group can reliably perform well on given your imaging mix, documentation workflows, reporting infrastructure, and subspecialty focus.

Start with the measures most aligned to your highest-volume modalities and workflows. A group performing a large volume of CT imaging may naturally support strong denominator counts for measures tied to radiation exposure and incidental findings follow-up. Groups with limited participation in certain imaging modalities may struggle to meet benchmark thresholds or minimum case volumes for particular measures.

QCDR measures can help fill reporting gaps, but they require participation in the NRDR. For groups already participating in ACR registries, incorporating QCDR measures into the reporting strategy is operationally straightforward. For groups that are not, the decision to join should weigh reporting advantages against onboarding time, registry costs, and workflow integration.

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

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 imaging exam identification and data capture. MIPS-eligible cases are tied to specific CPT and ICD-10 combinations, and if those cases are not consistently routed into the reporting workflow, they never reach the completeness denominator.

In radiology, this often involves coordination between:

• RIS/PACS systems
• Billing systems
• Structured reporting tools
• Registry interfaces
• EHR integrations

Other contributing factors include inconsistent documentation practices across radiologists, manual abstraction workflows, delayed registry uploads, and staffing turnover that disrupts established processes.

Timing also matters. Data completeness is measured across the full 12-month performance period. Groups that discover reporting gaps late in the year have limited recovery options. A measure sitting below threshold in Q4 may not recover before submission deadlines.

Practical Steps🔗

Reliable data completeness starts with automating identification of MIPS-eligible imaging studies. When capture depends on manual review, gaps accumulate quickly over the reporting year.

Quarterly validation checkpoints help groups identify completeness issues while there is still time to intervene. Assigning ownership for completeness monitoring to a dedicated team or compliance lead also improves accountability.

Documentation That Supports Numerator Criteria🔗

Measure performance in radiology 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 radiologist 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 radiology 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 contains defined numerator criteria: the specific reporting actions or documentation elements required for a case to count as a performance success.

For radiology measures, these often include:

• Radiation dose documentation
• Structured follow-up recommendations
• Appropriate use documentation
• Image quality standards
• Reporting timeliness
• Standardized incidental findings language

For example, measures tied to incidental findings follow-up require clear documentation of recommended follow-up imaging intervals and adherence to applicable clinical guidelines. If the report language does not align with measure specifications, the case may fall into the denominator without contributing positively to numerator performance.

Building Documentation Into Workflow🔗

Training radiologists on measure-specific documentation requirements is important, but sustainable improvement comes from embedding those requirements directly into structured reporting templates and reporting workflows.

Standardized macros, synoptic reporting tools, embedded follow-up recommendation language, and modality-specific templates reduce reliance on memory and improve consistency across the group.

A pre-submission review process — validating sample reports against numerator criteria before final submission — helps identify systematic documentation gaps while corrective action is still possible.

The cost of missing these patterns compounds over the course of the reporting year. A recurring documentation omission tied to one measure can produce poor numerator performance across hundreds or thousands of studies.

Improvement Activities for Radiology Groups🔗

Improvement Activities represent 15% of the final MIPS score for large radiology 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 Radiology Quality Improvement 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 radiology 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 Radiology Quality Improvement 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 radiology 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 Radiology MVP and 2026 Changes🔗

CMS continues to steer clinicians away from Traditional MIPS and toward MIPS Value Pathways (MVPs). Diagnostic radiology and intervention radiology MVPs have been finalized for the 2026 performance year, each with a curated set of measures relevant to that subspecialty. While the scoring methodology remains the same, MVPs bundle quality measures, improvement activities, and cost measures around a clinical theme.

Next Steps🔗

MIPS performance in radiology 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 radiology billing and revenue cycle management. Our team helps radiology groups navigate MIPS reporting requirements, optimize measure performance, and protect revenue. To evaluate your current MIPS reporting strategy, connect with our radiology billing team.

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