Steps to Wrap Up a Successful Performance Year

As the performance year comes to a close, it is important for clinicians and practices participating in MIPS to take a structured approach to year end activities. Strong performance in MIPS depends not only on the work done throughout the year, but also on the attention given to final data checks, documentation, and measure review before submission.

The recently released CY 2026 Final Rule confirms that CMS is keeping the MIPS program stable for the upcoming year. This consistency allows practices to complete their current reporting cycle with confidence, knowing that the core framework they have been using will continue forward. With that stability in place, the focus now shifts to closing out the current year successfully.

1. Confirm Your Quality Data Is Complete and Accurate

The most important year end task is verifying that all quality data has been captured. This includes confirming that each measure meets the 75 percent data completeness requirement and that performance rates reflect the services provided throughout the year.

Key steps include:

• Reviewing measure-level reports for missing data
  

• Confirming denominator accuracy
  

• Identifying outliers or unexpected performance shifts
  

• Ensuring data from all locations and EHR instances has been aggregated
  

If you plan to submit through a registry or QCDR, this is the time to ensure all data has been transmitted or is ready for extraction. Practices with topped out measures or measures flagged for low reliability should also consider whether alternative measures may better reflect current performance.

2. Review Your Improvement Activity Documentation

Improvement Activities require supporting documentation that aligns with CMS expectations. Before closing the year, practices should confirm:

• Each activity was performed for at least 90 continuous days
  

• Documentation is stored in a centralized location
  

• The activity matches the current year's inventory, not older versions
  

• Any team-based activities have clear evidence of staff participation
  

CMS introduced a few updates to the IA inventory for the upcoming year, but these do not change what is required for the period now ending. Ensuring your records are complete will help protect your score in the event of an audit.

3. Finalize Your Promoting Interoperability Requirements

Promoting Interoperability relies on a combination of EHR functionality, system configuration, and required attestations. Before closing the year, confirm the following:

• All required measures were enabled within your EHR
  

• Public health reporting submissions were active and successful
  

• The Security Risk Assessment was completed during the performance year
  

• Your EHR vendor has supplied the necessary reports for numerator and denominator values
  

Even as CMS prepares minor updates for the next performance year, the essential expectations remain the same. Accurate PI reporting begins with confirming that all components are in place before the year concludes.

4. Understand How Cost Will Influence Your Final Score

The Cost category is entirely claims based, but it still requires attention as the year ends. Review your available feedback reports to determine:

• Whether high-cost episodes are driving unexpected results
  

• If certain services or attribution patterns are affecting your profile
  

• Whether your clinicians are appropriately documented for exclusions
  

CMS will continue refining cost measures, but for this performance year, a clear understanding of attribution and performance can help explain your final score and guide strategic improvements next year.

5. Assess Whether You Met Your Performance Threshold

With the performance threshold remaining at 75 points, practices should review their projected scores across all four MIPS categories. This is also the right time to consider whether:

• Category reweighting applies
  

• You qualify for the small practice bonus
  

• Hardship applications were filed, if applicable
  

• Your measure and activity selections still reflect your clinical profile
  

By confirming your projected score now, you can identify any final adjustments that may help strengthen your overall performance.

6. Prepare Your Files and Audit Documentation for Submission

Before submitting your MIPS data, ensure that all required documents are saved, organized, and backed up securely. This includes:

• Quality reports
  

• PI reports and attestations
  

• Improvement Activity documentation
  

• Security Risk Assessment files
  

• Internal logs, workflows, or training evidence
  

• Any correspondence with vendors or public health agencies
  

Thorough recordkeeping reduces risk during audits and supports a smooth submission process.

Setting Up for a Strong Start Next Year

The 2026 Final Rule brings stability to the MIPS program. With no major structural changes or new reporting burdens, practices can focus on closing out the current year and then preparing for the next without having to rebuild foundational processes. This stability provides space to refine your strategies, explore measure alignment, or evaluate whether an MVP may be a future fit.

How Chirpy Bird Can Support Your Year End Wrap Up

Chirpy Bird assists providers with validating data, reviewing performance projections, selecting measures, organizing audit documentation, and preparing for final submission. Our team helps ensure your reporting is accurate, complete, and aligned with CMS expectations so you can move into the next performance year with confidence.

Partner with Chirpy Bird to wrap up your 2025 reporting and build a smart strategy for 2026 with guidance from our MIPS experts.