5 Common MIPS Mistakes Ophthalmology Practices Should Avoid

The Merit-based Incentive Payment System (MIPS) is increasingly complex and time-consuming for already-busy ophthalmology practices. For many teams, MIPS is just one more thing to keep track of on top of a busy clinical workload, leaving little time to understand the latest updates, monitor performance, or troubleshoot workflows. Some practices spend the entire year believing they’re on track, only to find out during the submission process that small oversights have led to missed points and unnecessary stress.

Practices that are proactive in avoiding common mistakes and identifying gaps throughout the year often see stronger results and less workload during reporting season. This post examines five common MIPS mistakes that ophthalmology practices should avoid to achieve a better score this performance year. 

Not Verifying Quality Measure Mapping     

Practices often assume that their Electronic Health Record (EHR) system is accurately tracking MIPS Quality measures. This assumption can lead to problems when the data being captured doesn’t align with the specifications of the measure. If data capture isn't aligned, the system may record incorrect values or miss qualifying encounters. Over time, these gaps add up and lower the performance score. Therefore, it’s important to verify that data for your Quality measures is being correctly captured in your EHR.

It’s also possible for ophthalmology EHR vendors to change how data is captured during software updates. Practices that rely on old workflows without checking current mappings could end up collecting incomplete or noncompliant data. Regular review of vendor documentation and technical updates is critical.

Many ophthalmology practices also rely on a registry to track and submit MIPS Quality measures. While registries can simplify reporting, they shouldn't be treated as “set it and forget it.” If your practice uses a registry, be sure to confirm regularly that data is being captured correctly. Gaps can lead to missed points if they aren’t addressed early.

Limited Staff Visibility

Oftentimes, not everyone in the ophthalmology practice understands how Quality measures are tracked in the EHR, creating risk when the informed staff leave or take on new roles. To avoid this, train your entire team on how Quality measures are tracked and ensure everyone understands how their daily workflow contributes. Internal audits or sample data checks each quarter can also help validate that everything is working as expected.

Delaying Promoting Interoperability Planning

The Promoting Interoperability (PI) category has a shorter reporting period than Quality, as it must be collected over a continuous 180-day period within the calendar year. Yet, many practices wait too long to begin planning for it. If practices miss the opportunity to select the right start date, they may lose flexibility and fall short of the required performance period.

The patient portal is also a required component of PI, and failing to report on it results in an automatic loss of 25 points. When workflows or systems change, patients often need new portal accounts, which can slow engagement if not addressed early. If your practice plans to switch ophthalmology EHRs this year, factoring in the time needed to re-enroll patients is essential.

Failing to Align Improvement Activities with Daily Operations

The Improvement Activities (IA) category is meant to reward practices for adopting workflows that enhance care quality. When activities are selected without regard to daily operations, it becomes harder to document progress and reach goals. Practices that align IAs with existing goals or projects see better follow-through and compliance. For example, if your team is already working on better care coordination, you can tie it to an IA rather than creating a new task from scratch. Practices should select activities they are already working on or are willing to commit to for the entire performance period.

Missing Validation Documents

Each Improvement Activity has specific validation rules that aren't always intuitive. Even if your practice successfully performs an activity, missing reports, screenshots, or patient logs can result in lost points during attestation. Create a documentation plan at the start of your 90-day IA performance period and assign a staff member to maintain a file with the required validation materials.

Promoting Staff Involvement

Improvement Activities should be part of team conversations. Staff who help implement them should understand what the goals are and how their roles contribute to success. Internal feedback loops and quick huddles can improve adoption and lead to better performance.

Assuming Registry Reporting Will “Just Work”

Many ophthalmology practices submit MIPS data through a registry, which acts as a third party that collects and submits data to CMS on the practice’s behalf. A common mistake is assuming that once a registry is selected, reporting will continue smoothly, even after changes like switching EHRs, registries, or vendors.

In reality, these transitions typically call for additional setup and validation to ensure data is being captured and submitted correctly.

When Data Doesn’t Flow as Expected

Even when an EHR is compatible with a registry, data doesn’t always transfer cleanly without manual mapping to connect specific measures to the correct data fields in the EHR. Practices should allow time to test the connection and resolve errors well before submission deadlines. Confirming these details early prevents surprises later.

Failing to Document Setup

Another common oversight is relying on verbal confirmation that registry reporting is set up. Without written documentation confirming connectivity, mapping, and go-live dates, practices have little protection if issues arise during submission or a surprise audit.

Not all registries or EHR vendors offer strong support for MIPS setup, leaving practices to struggle when configuring settings or understanding logic. Before choosing a registry or new ophthalmology EHR partner, check the level of support offered and whether they provide MIPS-specific guidance.

Not Aligning the Team on MIPS Responsibilities

While assigning a MIPS team lead is advisable, MIPS success is not the responsibility of a single person. When the entire team understands the performance categories, current requirements, and how data capture works, reporting becomes more predictable and efficient.

Training Gaps

In many practices, MIPS knowledge is isolated to one manager or staff member, which increases risk. Shared responsibility and regular team check-ins build a stronger compliance culture and help catch issues early. As CMS requirements change or workflows evolve, staff should receive updates. Short monthly check-ins are often enough to maintain awareness and reinforce expectations.

Role Clarity

Whether it’s flagging specific encounters, uploading documentation, or reviewing dashboards, each team member needs to know how they contribute to your practice’s score. Teams that meet regularly to review performance are also better equipped to make course corrections throughout the year, rather than scrambling at the end.

Getting MIPS Right Starts Early

Ophthalmology practices that want to succeed in MIPS reporting need more than just technical readiness. Avoiding common mistakes, like not verifying mapping, delaying planning, or failing to align your team on shared goals, can be the difference between achieving a higher score and losing points this year.

Sightview’s MIPS consulting services help practices avoid these mistakes and build systems that support consistent performance. Our MIPS customers achieve scores nearly 9 points higher than the national average. To learn more about how our MIPS experts can support your team in maximizing reimbursements, contact us here.