Quality Payment Program: Engaging in Improvement Activity for the Merit-based Incentive Payment System

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In this column, we explore another pillar of the Merit-based Incentive Payment System (MIPS) called Improvement Activity. The following information is directly referenced from the MIPS Improvement Activities Fact Sheet.1
The Improvement Activity performance category within MIPS assesses how much you participate in activities that improve clinical practice. Examples include ongoing care coordination, shared decision making, regular implementation of patient safety practices, and expanding practice access. Under this performance category, you will be able to choose from many activities to demonstrate your performance. This performance category also includes incentives that help drive participation in certified patient-centered medical homes and Advanced Alternative Payment Models (APMs).
You will be able to choose from activities listed under the Improvement Activity inventory. The inventory for the first year of MIPS is currently listed on the Quality Payment Program website as well as in Table H of the Appendix in the Quality Payment Program Final Rule. The inventory contains activities that are divided into 9 subcategories: Expanded Practice Access, Population Management, Care Coordination, Beneficiary Engagement, Patient Safety and Practice Assessment, Participation in an APM, Achieving Health Equity, Integrating Behavioral and Mental Health, and Emergency Preparedness and Response.
Eligible clinicians may submit their improvement activities by attestation via the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program website, a qualified clinical data registry (QCDR), a qualified registry, or, when possible, from their electronic health record (EHR) system. Groups of 25 or more may choose to use the CMS Web Interface. Eligible clinicians and groups need to attest only via the Quality Payment Program website that they completed the improvement activities they selected, or they should work with their vendor to determine the best way to submit their activities via a QCDR, a qualified registry, or their EHR system. Eligible clinicians are encouraged to retain documentation for 6 years as required by the CMS document retention policy.
The following are the necessary reporting criteria:
Scoring for groups with more than 15 clinicians: Each activity is weighted either medium or high. To get the maximum score of 40 points for the Improvement Activity score, you may select any of these combinations: 2 high-weighted activities, 1 high-weighted activity and 2 medium-weighted activities, or up to 4 medium-weighted activities. Each medium-weighted activity is worth 10 points of the total Improvement Activity performance category score, and each high-weighted activity is worth 20 points of the total category score. If you are not participating in an APM, a certified patient-centered medical home, or comparable specialty practice, and you do not select any activities, you will receive 0 points in this performance category.
Scoring for groups with 15 or fewer clinicians, non–patient-facing clinicians, and/or clinicians located in a rural area or Health Professional Shortage Area. Again, each activity is weighted either medium or high. To achieve the maximum 40 points for the Improvement Activity score, you may select either of these combinations: 1 high-weighted activity or 2 medium-weighted activities. For these clinicians, each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and a high-weighted activity is worth 40 points of the total category score. These clinicians may select 2 medium-weighted activities or 1 high-weighted activity to receive a total of 40 points of the total category score.
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