In the final part of this series, we will explore the Improvement Activities and how to get the maximum score. To learn how to optimize the score for Quality and Advancing Care Information, read my previous blogs. Improvement Activities (IA) is one of the four performance categories for MIPS and accounts for 15% of the Composite MIPS Score. IA assesses how much you participate in activities that improve clinical practice such as care coordination, patient safety, expanded practice access, patient engagement and population management.
Improvement Activity Scores: Clinicians can choose any of the 93 activities across the 9 sub-categories to achieve the maximum score of 40. The list of activities is available at https://qpp.cms.gov/mips/improvement-activities . The activities carry a score of 10 points for medium weighted activity and 20 points for high weighted activity. Groups of 15 or fewer clinicians, non-patient facing clinicians and those serving in Rural and Health Professional Shortage Areas receive a score of 20 points for medium weighted activity and 40 for high weighted activity. Participants in the Improvement Activity Study receive full credit.
Some of the activities fetch 10% bonus points under the Advancing Care Information Performance Category if Clinicians attest to performing them using a certified EHR. Table A lists the ACI bonus supported activities.
Table A: List of CEHRT Supported Activities
APM Scoring Standard: MIPS APM and Eligible Clinicians in Advanced APM who do not meet the threshold to become Qualified Participants receive special MIPS Scoring under the “APM Scoring Standard” and have the Improvement Activities reweighted as follows:
- For the Shared Savings Program and the Next Generation ACO Model, improvement activities performance category weight is 20 percent.
- (For MIPS APMs other than the Shared Savings Program and the Next Generation ACO Model (which includes the CPC+ Model, the CEC Model, and the OCM), improvement activities performance category weight is 25 percent.)
Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home automatically earn full credit. Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. (For all future APMs under the APM scoring standard, the assigned score will be at least half credit. Participants in any other APM automatically earn half credit. They may report additional activities to increase their score. )
Submitting Improvement Activities:
- Clinicians have to attest “Yes” to the activities they performed for at least 90 consecutive days during the performance period.
- If submitting as a group, only one eligible clinician in a TIN may perform the Improvement Activity for the TIN to get credit.
- Clinicians can choose the activities that are most meaningful to their practice. There is no requirement of subcategory.
- Improvement Activities can be submitted through attestation on the CMS QPP portal, Certified EHR, Qualified Registry, and Qualified Clinical Data Registry (QCDR). Group of 25 or more clinicians can also report through the CMS web interface.
- If reporting through a QCDR, clinicians must select and achieve each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR.
- Clinicians should retain the documentation for 6 years as part of CMS documentation retention policy. Guidelines on what is required for each improvement activity, validation criteria, and suggested documents are published by CMS and can be downloaded from https://qpp.cms.gov/docs/QPP_MIPS_Data_Validation_Criteria.zip.
Achieving 100% (full 40 points) in Improvement Activities:
- Are you a patient centered medical home? You automatically receive full credit.
- Are you a part of advanced APM? Check the https://qpp.cms.gov/docs/QPP_APMs_and_Improvement_Activities.pdf to find out your Improvement Activity Score.
- Are you a small practice (less than 15 physicians), non-patient facing clinician or serve in Rural and Health Professional Shortage Areas? You only need to do 1 high-weighted activity or 2 medium-weighted activity.
- Choose the appropriate activities. Go through the entire list of activities along with the required documentation for each activity from https://qpp.cms.gov/docs/QPP_MIPS_Data_Validation_Criteria.zip.
- Are there activities that you currently do?
- Are there activities that you could start doing without additional burden?
- Does your EHR support the activities eligible for EHR bonus under ACI?
- Consider activities that can fetch you additional revenue streams such as CCM (Chronic Care Management) or Tele-Medicine.
Would you like to know about Improvement Activities in 2017?
About the Author:
Arnaz Bharucha is the R&D Lead for Quality Improvement and Senior Software Architect with over 17 years of experience in designing and supporting healthcare IT products for Electronic Health Record, Quality Reporting for MIPS, Meaningful Use, PQRS, PCMH, DOQ-IT etc., and professional & institutional medical billing systems. She has shouldered key responsibilities of understanding the US Healthcare industry standards, designing iPatientCare suite of products in compliance with the ONC’s Meaningful Use, designing and implementing interoperability and other healthcare Quality Reporting initiatives requirements. Under her leadership, iPatientCare has been a Qualified Registry for submitting quality measures to CMS since 2014.