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MIPS Category: Improvement Activities

Improvement Activities Category Weight – 15%

For 2019, the third performance year of MIPS, CMS will weight a provider’s Improvement Activities score at 15% of the overall MIPS final score. 

Improvement Activities Reporting Requirements

Physicians must achieve a total of 40 points from improvement activities during a 90-day reporting period. CMS will score individual improvement activities as either high- or medium-weighted. High-weighted activities are worth 20 points, while medium-weighted activities are worth 10 points. Providers are required to perform four medium-weighted or two high-weighted activities, or any combination of high- or medium-weighted activities for 2019.

Physicians in groups of 15 or fewer are only required to complete one high-weighted or two medium-weighted activities for full credit—40 points—for the category. For small practices, CMS will weigh the improvement activities at double the value for larger practices. Therefore, high-weighted activities are worth 40 points, while medium-weighted activities are worth 20 points. Providers in groups of 15 or fewer can achieve half of the total category score by completing one medium-weighted improvement activity.

Providers participating in a patient-centered certified medical home will automatically receive full credit for the Improvement Activities category of MIPS. Physicians and groups participating in an Advanced APM or MIPS APM will automatically receive at least 50% of the full score for the Improvement Activities category. 

Improvement Activities Score

To determine a provider’s Improvement Activities category score, CMS will divide the sum of the points earned by the provider by 40, the total available points for the category. The Improvement Activities category score would then be counted as 15% of the MIPS final score. 

Ophthalmology Improvement Activities

For 2019, CMS finalized a new ophthalmology-specific improvement activity: Comprehensive Eye Exam. For this medium-weighted activity, participants must promote the importance of a comprehensive eye exam, which may be accomplished by providing literature or facilitating conversation about the topic using materials created by the American Academy of Ophthalmology or the American Optometric Association.

Improvement Activities

The final rule includes a list of all individual improvement activities. The activities are grouped in eight sub-categories corresponding to CMS’ stated goals. Providers may choose any combination of improvement activities, regardless of category.

The categories and examples of activities included are listed below:

  • Expanded Practice Access: Improvement activities include expanded practice hours, telehealth services, and participation in models designed to improve access to services.
  • Population Management: Improvement activities include participation in chronic care management programs, participation in rural and Indian Health Services programs, participation in community programs with other stakeholders to address population health, and use of a Qualified Clinical Data Registry (QCDR) to track population outcomes.
  • Care Coordination: Improvement activities include use of a QCDR to share information, timely communication and follow up, participation in various CMS models designed to improve care coordination, implementation of care coordination training, implementation of plans to handle transitions of care, and active referral management.
  • Beneficiary Engagement: Improvement activities include use of EHR to document patient-reported outcomes, providing enhanced patient portals, participation in a QCDR that promotes the use of patient engagement tools, and use of QCDR patient experience data to inform efforts to improve beneficiary engagement.
  • Patient Safety and Practice Assessment: Improvement activities include use of QCDR data for ongoing practice assessments and patient safety improvements, as well as use of tools, such as the Surgical Risk Calculator.
  • Achieving Health Equity: Improvement activities include seeing new and follow-up Medicaid patients in a timely manner and use of QCDR for demonstrating performance of processes for screening for social determinants.
  • Emergency Response and Preparedness: Improvement activities include participation in disaster medical teams or participation in domestic or international humanitarian volunteer work.
  • Integrated Behavioral and Mental Health: Improvement activities include tobacco intervention and smoking cessation efforts, and integration with mental health services.

For the full list of proposed improvement activities, please refer to the CMS website: https://qpp.cms.gov/measures/ia.

Data Submission

Providers can submit improvement activities data using the following mechanisms: qualified registry, EHR, QCDR, CMS Web Interface, and attestation data submission mechanisms. In 2019, all submission mechanisms must designate a “yes/no” response for submitting improvement activities. 

Additional Resources

For additional information, you may contact Allison Madson, manager of regulatory affairs, at amadson@ascrs.org or 703-591-2220. 

Educational Resources