I hear the most interesting things about when Medicare rules apply and about the requirements of the Merit-Based Incentive Payment System (MIPS). For example, two years ago, a doctor whose practice involved the application of CTPs/skin substitutes on patients in the home setting told me with confidence that Medicare coverage polices around CTPs/skin substitutes did not apply if a Medicare beneficiary was seen in the home setting. “All those Medicare coverage rules are only for patients in hospitals and skilled nursing units,” he said. He also said that he did not need to worry about recording any details of the wound treatment history or the patient’s medical history because, “the home health agency has all that stuff.” I nearly laughed out loud. But it seems there are a lot of myths about Medicare when patients are seen at home. Recently, a practitioner told me that he did not have to report any MIPS data because his mobile practice sees patients exclusively in the home setting. I have news for him — he might lose 9% of his Medicare billing — unless he is exempt from MIPS for other reasons detailed below.
MIPS Applicability for Home-Based Clinicians
Practitioners who see patients exclusively at home are still subject to MIPS (Merit-based Incentive Payment System) if they meet the eligibility criteria. The key determinant for MIPS inclusion is not the practice location but the volume of services billed to Medicare Part B, the number of beneficiaries served and/or the amount billed.
MIPS Eligibility Criteria (Regardless of Setting)
- Eligible Clinician Status:
MIPS applies to Medicare Part B providers billing under the Physician Fee Schedule, including MDs, NPs, PAs, PTs, OTs, and social workers.
- Volume Thresholds:
You are included in MIPS if, during the determination period, you exceed all three of the following:
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- More than $90,000 in Medicare Part B allowed charges
- More than 200 Medicare beneficiaries
- More than 200 Medicare Part B services
- APM Participation:
If you a “Qualifying Participant” in an Advanced Alternative Payment Model (APM) then you are exempted from MIPS.
- New Enrollee Exception:
First-time Medicare enrollees are exempt during their initial performance year.
Practice Location Doesn’t Change Applicability
CMS determines MIPS eligibility based on NPI/TIN combinations, patient volume, and reimbursement — not based on practice location. Even if services are delivered only in patients’ homes (Place of Service Code 12), MIPS requirements apply if the thresholds are met.
Summary Table
| Scenario | MIPS Applies? | Notes |
| Home-based clinician meets volume thresholds | ✅ Yes | Must report MIPS (“eligible” is Medicare’s term for “must”); location is irrelevant |
| Eligible clinician but below thresholds | ❌ No | Not required (can “opt in” or volunteer) |
| In QP Advanced APM | ❌ No | Exempt from MIPS |
| First-year Medicare enrollee | ❌ No | Exempt for that performance year |
Bottom line: Home-based clinicians are not exempt from MIPS if they meet the volume thresholds and are not otherwise excluded (e.g., APM participation, new enrollee). (And by the way, Medicare coverage policies around CTP/skin substitutes are not waived because a patient is being seen at home.)
I don’t know how these myths get started, but they are potentially expensive mistakes. Don’t take my word for it, look up the MIPS eligibility requirement using the practitioner’s NPI number.
–Caroline
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
