MIPS Low-Volume Threshold: 3 Criteria Explained
The MIPS low-volume threshold is the Medicare Part B volume test that decides whether an eligible clinician must report MIPS. It has three criteria for 2026. The tests are more than $90,000 in Part B allowed charges, more than 200 Part B beneficiaries, and more than 200 covered professional services. A clinician must exceed all three to be required to report. Falling at or below any one criterion excludes the clinician, who may opt in or report voluntarily.
What Is The MIPS Low-Volume Threshold?
The MIPS low-volume threshold is the volume test that, together with the clinician-type test, determines whether a clinician is required to report MIPS. The low-volume threshold measures Medicare Part B activity across three dimensions: allowed charges, beneficiaries served, and covered professional services furnished. A clinician clears the volume gate only by exceeding every dimension.
The low-volume threshold works alongside the clinician-type test, and a clinician must satisfy both gates. The low-volume threshold is not the MIPS performance threshold. The MIPS performance threshold is a 75-point scoring benchmark that sets payment adjustments, not eligibility.
How Does The Low-Volume Threshold Decide If You Must Report MIPS?
A clinician must exceed all three low-volume criteria and be an eligible clinician type to be required to report MIPS. Exceeding all three volume criteria makes reporting mandatory for that performance year. Sitting at or below any single criterion excludes the clinician from the reporting requirement.
The exclusion applies even when the other two criteria are exceeded by a wide margin. This all-or-nothing structure is the core of the low-volume threshold. The full Required, Excluded, Opt-in, and Voluntary outcomes appear in the decision table further down this page.
Does The Low-Volume Threshold Apply To Your Clinician Type?
Only if your clinician type is MIPS eligible. The low-volume threshold applies after the clinician-type test. If your type is not on the CMS list, you are excluded regardless of volume. If your type qualifies, the low-volume threshold then decides whether reporting is required. Confirm your designation against the current MIPS eligible clinician types before checking volume.
How Does The Low-Volume Threshold Fit Into The MIPS Eligibility Criteria?
The low-volume threshold is one of the tests inside the broader MIPS eligibility criteria, alongside the clinician-type test and the new-enrollee and QP exemptions. The clinician-type test screens the role first. The low-volume threshold screens billing volume second.
Two further exemptions sit inside the same framework:
- New Medicare enrollees are excluded for their first partial year of Medicare participation.
- Qualifying APM Participants (QPs) are excluded because they report through an Advanced Alternative Payment Model.
- The low-volume threshold does not override either exemption, even when a clinician exceeds all three volume criteria.
Each test resolves a different eligibility question, and CMS applies the tests together. For the full framework, including the clinician-type test and both exemptions in depth, see the MIPS eligibility criteria.
What Are The Three Low-Volume Threshold Criteria?
The three low-volume threshold criteria for 2026 are unchanged from 2025. Each criterion uses a “more than” operator, so the exact threshold value alone does not trigger the requirement. The table below lists each criterion, its 2026 threshold, and what CMS counts.
| Criterion | 2026 Threshold | What CMS Counts |
|---|---|---|
| Medicare Part B allowed charges | More than $90,000 | Allowed charges for covered professional services |
| Medicare Part B beneficiaries | More than 200 | Distinct Part B-enrolled patients served |
| Covered professional services | More than 200 | Services furnished to Part B beneficiaries |
A clinician who bills exactly $90,000, serves exactly 200 beneficiaries, or furnishes exactly 200 services does not exceed that criterion.
Medicare Part B Allowed Charges (More Than $90,000)
Criterion 1 is more than $90,000 in Medicare Part B allowed charges for covered professional services during the determination period. Allowed charges are the CMS-approved amounts, not the amounts a clinician bills. A clinician at or below $90,000 in allowed charges does not exceed this criterion.
Medicare Part B Beneficiaries (More Than 200)
Criterion 2 is care provided to more than 200 Medicare Part B-enrolled beneficiaries during the determination period. CMS counts distinct beneficiaries, so repeat visits by one patient count once. A clinician serving 200 or fewer beneficiaries does not exceed this criterion.
Covered Professional Services (More Than 200)
Criterion 3 is more than 200 covered professional services furnished to Part B beneficiaries during the determination period. Covered professional services are services billed under the Medicare Physician Fee Schedule. A clinician furnishing 200 or fewer covered professional services does not exceed this criterion.
How Are The Three Criteria Combined To Determine Eligibility?
CMS combines the three criteria with AND logic. A clinician is required to report MIPS only when they exceed all three during the determination period. The number of criteria a clinician exceeds sets four distinct outcomes, mapped in the table below.
| Volume Result | MIPS Status | Reporting Path and Adjustment |
|---|---|---|
| Exceeds all three criteria | Required | Must report; receives a payment adjustment |
| At or below any one criterion | Excluded | Not required to report |
| Exceeds one or two criteria | Excluded, opt-in available | May opt in (irrevocable) and receive an adjustment |
| Exceeds none of the criteria | Excluded, voluntary only | May report voluntarily; no payment adjustment |
Exceeding two of three criteria still leaves a clinician excluded, because AND logic requires all three.
Working example. A nurse practitioner bills $120,000 in allowed charges, which exceeds $90,000. The same clinician serves 250 beneficiaries, which exceeds 200. The clinician furnishes 180 covered professional services, which does not exceed 200. This clinician exceeds two of three criteria. The clinician is not required to report, but may opt in.
Two other exclusions sit outside this volume math. New Medicare enrollees and Qualifying APM Participants are excluded on separate grounds, treated in depth within the overall MIPS eligibility criteria.
How Does MIPS Opt-In Work If You Exceed Some But Not All Criteria?
Clinicians who fall below the full threshold have two paths: opt-in or voluntary reporting. The path depends on how many criteria the clinician exceeds. The two paths carry different consequences for payment adjustments.
Opt-In Election (Exceed One or Two Criteria)
Clinicians and groups that exceed one or two criteria may make an opt-in election. The election is submitted in the QPP portal and is irrevocable for the performance year. An opt-in clinician receives a MIPS payment adjustment, positive or negative, based on the final score. Opt-in suits practices confident of scoring above 75 points.
Voluntary Reporting (Exceed None)
Clinicians who exceed none of the three criteria may report voluntarily. Voluntary reporting returns performance feedback and reporting experience. Voluntary reporting does not carry a MIPS payment adjustment, positive or negative. Practices use voluntary reporting to prepare for a future year when volume rises above the threshold.
When Does CMS Determine Your Low-Volume Status?
CMS evaluates low-volume status across two 12-month determination segments. Being at or below the threshold in either segment excludes the clinician for the year. CMS draws the data from Medicare Part B claims and PECOS enrollment records. The two 2026 segments use fixed dates.
| Determination Segment | Date Range (2026 Performance Year) |
|---|---|
| Segment 1 | October 1, 2024 to September 30, 2025 |
| Segment 2 | October 1, 2025 to September 30, 2026 |
Determination Segment 1 (October 1, 2024 – September 30, 2025)
Segment 1 is the first 12-month claims window CMS uses for 2026 eligibility. CMS released initial 2026 status from Segment 1 in 2025. A clinician below the threshold in Segment 1 is excluded for 2026.
Determination Segment 2 (October 1, 2025 – September 30, 2026)
Segment 2 is the second 12-month window and captures clinicians who join a new practice mid-year. CMS publishes final 2026 eligibility from Segment 2 in December 2026. A new TIN is evaluated in Segment 2 only.
How Does The Threshold Apply To Groups And APM Entities?
The low-volume threshold is calculated at the TIN/NPI level for individuals and at the TIN level for groups. The unit of measurement changes the result. A clinician excluded as an individual can still enter MIPS through a reporting group.
CMS applies three calculation units:
- Individual: volume is summed for one TIN/NPI combination.
- Group: volume is summed across all clinicians billing under a single TIN.
- APM Entity group: volume is assessed collectively for the entity’s participants.
A group that exceeds the low-volume threshold as a whole must report at the group level. Virtual groups follow the same collective calculation. Group-level reporting mechanics sit outside this page.
Did The MIPS Low-Volume Threshold Change For 2026?
No. The three low-volume-threshold criteria are unchanged for the 2026 performance year. More than $90,000 in allowed charges, more than 200 beneficiaries, and more than 200 covered professional services remain the tests. CMS confirmed the stability in the CY2026 Physician Fee Schedule Final Rule, published November 5, 2025.
The low-volume threshold is not the MIPS performance threshold. The MIPS performance threshold remains 75 points and governs scoring, not eligibility. CMS committed to holding the 75-point performance threshold through the 2028 performance year.
How Does Macralytics Check Your Low-Volume Threshold Status?
Macralytics calculates each clinician’s low-volume status before the reporting year. The process follows four steps:
- Pull Medicare Part B charges, beneficiaries, and services per TIN/NPI.
- Test each figure against the three criteria across both determination segments.
- Flag each clinician as required, excluded, opt-in eligible, or voluntary.
- Advise on the opt-in decision where a clinician exceeds one or two criteria.
The output tells a practice who must report and where an opt-in election changes the payment outcome. Run a MIPS eligibility check before the performance year begins.
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