Quality Payment Program (QPP) Guidance for Clinical Social Workers in 2025
Denise Johnson, LCSW-C,
Senior Practice Associate, Clinical Social Work
On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released updates to the Quality Payment Program (QPP) as part of the 2025 Physician Fee Schedule (PFS). These updates are also available in the QPP Resource Library. Established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the QPP provides tools and resources for Medicare providers.
Clinical social workers (CSWs) participating in QPP as eligible clinicians can receive a positive payment adjustment of up to 9% for accurate reporting of quality measures. However, incorrect reporting can result in a negative adjustment of up to 9%. This document outlines updates specifically relevant to CSWs eligible for QPP participation.
Eligibility
CSWs participate in QPP through the Merit-based Incentive Payment System (MIPS). MIPS is a Medicare program that adjusts payments based on performance in four areas: quality, cost, improvement activities, and promoting interoperability. To qualify as MIPS-eligible, CSWs must exceed the annual low-volume threshold either individually or as part of a group, meeting all three of the following criteria:
- Bill more than $90,000 for Medicare Part B covered professional services
- See more than 200 Medicare Part B patients
- Provide more than 200 covered professional services to Medicare Part B patients.
Clinicians exceeding all three criteria are required to participate and report under MIPS. Those meeting only one or two criteria are not required to participate or report.
For more details, CSWs can review the MIPS Eligibility page or use the QPP Participation Status Tool to confirm their eligibility status. A finalized list of measures for the CSW specialty set is below.
- Advance Care Plan: Tracks the percentage of patients aged 65 and older who have an advance care plan or have discussed it with their healthcare provider.
- Documentation of Current Medications in the Medical Record: Tracks the percentage of visits where clinicians document a list of current medications for patients aged 18 and older.
- Preventive Care and Screening: Screening for Depression and Follow-Up Plan: Measures the percentage of patients aged 12 years and older screened for depression using a standardized tool, with a documented follow-up plan if the screening is positive.
- Elder Maltreatment Screen and Follow-Up Plan: Tracks the percentage of patients aged 60 years and older who are screened for elder maltreatment and have a documented follow-up plan if the screen is positive.
- Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Measures the percentage of patients aged 12 years and older who are screened for tobacco use and receive cessation intervention if identified as a tobacco user.
- Dementia: Cognitive Assessment: Measures the percentage of patients with dementia who receive a cognitive assessment at least once a year.
- Dementia: Functional Status Assessment: Measures the percentage of dementia patients who receive a functional status assessment annually.
- Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia: Assesses the percentage of dementia patients who are screened for safety concerns and receive follow-up if needed.
- Dementia: Education and Support of Caregivers for Patients with Dementia: Tracks the percentage of dementia patients whose caregivers receive education and support resources.
- Initiation and Engagement of Substance Use Disorder Treatment: Assesses the percentage of patients aged 13 years and older with a new substance use disorder episode who initiate and engage in treatment within specified time frames.
- Depression Remission at Twelve Months: Measures the percentage of patients with major depression or dysthymia who achieve remission 12 months after an index event.
- Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment: Measures the percentage of patient visits for children and adolescents with MDD that include a suicide risk assessment
- Adherence to Antipsychotic Medications for Individuals with Schizophrenia: Measures the percentage of individuals with schizophrenia who consistently take their prescribed antipsychotic medications
- Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Measures the percentage of patients aged 18 years and older who are screened for unhealthy alcohol use and receive brief counseling if identified as an unhealthy alcohol user.
- Screening for Social Drivers of Health: Tracks the percentage of patients aged 18 years and older screened for social needs such as food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.
- Connection to Community Service Provider: Assesses the percentage of patients who screen positive for certain health-related social needs and are connected to a community service provider.
- Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder: Measures the percentage of individuals aged 18 and older with a mental and/or substance use disorder who demonstrate improvement or maintenance of functioning based on standardized assessments.
- Initiation, Review, And/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, Or Suicide Risk: Assesses the percentage of adults aged 18 years and older with suicidal ideation or behavior who have a suicide safety plan initiated, reviewed, and/or updated in collaboration with their clinician.
- Reduction in Suicidal Ideation or Behavior Symptoms: Measures the percentage of patients aged 18 and older with mental and/or substance use disorders who demonstrate a reduction in suicidal ideation and/or behavior symptoms based on standardized assessments.
Measure/Activity Inventories and Scoring Methodologies
CMS has made updates to Measure/Activity Inventories and Scoring Methodologies for traditional MIPS and MIPS Value Pathways (MVPs). NASW has been supportive of many of these revisions, particularly those that streamline reporting requirements and reduce administrative burden. The updates are as follows:
- New Quality # 503, Gains in Patient Activation Measure (PAM) Scores at 12 Months—proposed addition
CMS finalized the addition of the "Gains in Patient Activation Measure (PAM®) Scores at 12 Months" to the Clinical Social Work Specialty Set for the 2025 performance period. This measure evaluates changes in patients' knowledge, skills, and confidence in managing their health, emphasizing its relevance across care settings and its focus on chronic conditions. NASW supported the inclusion of this measure while highlighting implementation challenges, such as resource requirements, and recommended solutions like training and integrating the measure into electronic health record systems to improve feasibility and consistency.
- Modified: Quality # 181 Elder Maltreatment Screen and Follow-Up Plan
Q181 measures the percentage of patients 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter and a documented follow-up plan on the date of the positive screen. CMS finalized its proposal to add this CQM to the Emergency Medicine Specialty Set for the CY 2025 performance period/2027 MIPS payment year and future years. In its comments on the proposed rule, NASW strongly supported CMS’s proposal, noting that that the emergency department is a prime setting for elder maltreatment identification and follow-up planning. Furthermore, in response to CMS’s request for input on the value of any CQM addressed in the final rule, NASW emphasized the relevance of Q181 within the measure specialty sets for clinical social workers and skilled nursing facilities.
- Modified: Quality # 504, Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk—proposed change to a previously finalized measure
Quality # 504 is a high priority clinical quality measure (CQM) that provides suicide assessment and safety planning data. CMS proposed updating the measurement criteria from patients 18 years and older to patients 12 years and older. NASW supported this proposed change but also recommended lowering the age further to 10 years and older.
CMS reviewed public comments and maintained the initial proposal of 12 years and older. However, CMS also provided guidance to discuss potential updates to this measure in the future. CMS encouraged public commenters to discuss a lower age range with the measure steward, the American Psychiatric Association. NASW appreciates the opportunity to discuss this measure, so data is captured for child, adolescent and adult patients impacted by suicide ideations and risks.
Final Scoring
The performance weight categories for 2025 are:
- Quality Performance Category: 30%
- Cost Performance Category: 30%
- Improvement Activities Performance Category: 15%
- Promoting Interoperability Performance Category: 25%
Performance Category Reweighting
Clinicians may request reweighting of the quality, improvement activities, and/or Promoting Interoperability categories if data submission is prevented due to issues beyond their control. This applies when a third-party intermediary, under a written agreement, fails to submit data by the deadlines. CMS evaluates requests based on the clinician's awareness of the issue, efforts to address it, and whether it resulted in no data submission. Requests must be submitted to the QPP Service Center by November 1 of the year before the MIPS payment year and will be accepted starting with the CY 2024 performance period for the 2026 payment year.
Performance Threshold
CMS has finalized rules to maintain consistency in the MIPS program by keeping the performance threshold at 75 points for the CY 2025 performance period, based on the CY 2017 mean final score. This methodology will continue through CY 2027, impacting the 2029 payment year. The 75% data completeness threshold will also remain in place through the CY 2028 performance period, affecting the 2030 payment year.
Extreme and Uncontrollable Circumstances (EUC)
CMS has determined that the MIPS automatic EUC policy will apply to MIPS eligible clinicians in counties affected by Hurricanes Milton, Helene, and Francine in:
- Florida
- Georgia
- North Carolina
- South Carolina
- Tennessee
- Louisiana
CSW‘s are encouraged to review the 2024 MIPS Automatic Extreme and Uncontrollable Circumstances Policy Fact Sheet for more information.
Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs)
CMS continues to advance MVPs by updating measure and activity inventories and scoring methodologies to support clinician participation. Calendar Year 2025 finalized policy for scoring population health measures in the Quality Performance Category under the MVP framework streamlines the process for participants. CMS will calculate all available population health measures for each MVP participant and automatically apply the highest scoring measure to their quality performance category score. This means MVP participants no longer need to select a population health measure during the MVP registration process, simplifying participation and ensuring the most favorable scoring outcome.
New updates include measures like Anxiety Response at Six Months, PTSD Outcome Assessments for Adults and Children, and Reduction in Suicidal Ideation or Behavior Symptoms, expanding the range of conditions assessed. The addition of measures for Suicide Safety Planning and continuity of pharmacotherapy for opioid use disorders strengthens the focus on prevention and consistent treatment.
The MVP also incorporates health equity by introducing screenings for social drivers of health, such as housing instability and food insecurity, to address factors that influence mental health outcomes. Improvement activities now encourage the use of integrated patient-centered behavioral health models, increased focus on care for maternal and geriatric populations, and the adoption of patient-reported outcome tools to enhance care delivery.
The CY 2025 finalized policy applicable to MIPS Value Pathways (MVPs) maintains the requirement that subgroups participating in MIPS must submit their affiliated group’s data for the Promoting Interoperability performance category. This continuation of the existing policy ensures consistent reporting practices for subgroups under the program.
How to Register
CSWs can visit the QPP website to find more information on Timeline and Important Deadlines along with information on the registration process.
Due to the complexities of reporting and to avoid a negative penalty adjustment, NASW strongly recommends using a mental health registry for the reporting of measures. A registry is a vendor that collects data from an eligible MIPS individual clinician or group and submits the data to Medicare on their behalf. There is a fee associated with the use of a registry. Registries that report mental health and substance use disorder quality measures include, but are not limited to, the following:
For Help and Additional Information
Assistance is also available from NASW by emailing Denise Johnson, LCSW-C, Senior Practice Associate, at clinical.practice@socialworkers.org.