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MIPS Improvement Activities: Medicare’s New Concept in Quality Reporting

With the first performance year of the Merit-Based Incentive Payment System (MIPS) well under way, it is now more important than ever to educate yourself on how to comply with the new quality reporting requirements. Many practices are now familiar with the four categories under MIPS that will be used to determine an Eligible Clinician’s overall Final Score: Quality, Cost (starting in the 2019 performance year), Advancing Care Information, and Improvement Activities. But understanding what each of these categories represents and how they should be reported remains a struggle for many.

Medicare’s New Concept in Quality Reporting

2017 Improvement Activities Guide

That’s where Mingle Health comes in. We’re here to help you succeed with Medicare’s new Quality Payment Program (QPP) and to help ease the stress and burden of reporting. That’s why we feel it is important to educate you on the newest category “Improvement Activities.”

The goal of this category is to improve clinical practice in areas such as care coordination, beneficiary engagement, and patient safety. The activities are organized under eight subcategories and account for 15% of the overall Final Score in the first year of MIPS.

What You Need to Know About Scoring

Each activity is assigned points based on their rating as a high- or medium-weighted activity. High-weighted activities are worth 20 points; medium-weighted activities are worth 10 points. Most Eligible Clinicians will need to attest to up to four activities worth a total of 40 points to achieve full credit for this category towards their Final Score.

Practices who are recognized as a patient-centered medical home (PCMH), or comparable specialty designation, will automatically receive the full 40 points.

Most of the organizations operating under an Alternative Payment Model (APM) such as a Medicare Shared Savings Plan (MSSP) are required to participate in several improvement activities. Those activities, which are required by participation in the APM, will earn full credit for the improvement activity category.

Eligible Clinicians who signed up to participate in a CMS-sponsored improvement activity study, by the January 1, 2017, deadline will automatically receive full credit.

There is special scoring for each Improvement Activity for certain Eligible Clinicians. Groups that meet the following criteria receive double points in this category:

  • Non-patient-facing Eligible Clinicians
  • Practices with 15 or fewer Eligible Clinicians
  • Practices in rural practice areas
  • Practices in a geographic Health Professional Shortage Areas (HPSA)

Some items to keep in mind when selecting activities:

  • You can select a combination of high- and medium-weighted activities to earn a total of 40 points, and need to choose at least one to receive any points in this category.
  • Most activities must be performed for at least 90 days during the performance year.
  • Certain activities give bonus points in the Advancing Care Information category if using Certified Electronic Health-Record Technology (CEHRT) to perform the activity.
  • For 2017 only, CMS is allowing Eligible Clinicians to report on just one Improvement Activity to avoid the penalty as part of the “Pick Your Pace” option.
  • If reporting the other categories as a group, Improvement Activities are also reported as a group. When reporting as a group, if at least one Eligible Clinician within the group is performing the activity for a continuous 90-days in the performance period, the whole group gets credit for the activity.
Subcategory Overview

Eligible Clinicians have over 90 activities to choose from during the 2017 performance year, organized into eight subcategories which we’ve listed below:

Achieving Health Equity
Example Activity: Seeing new Medicaid Patients in a Timely Manner
Behavioral and Mental Health
  Example Activity: Colocation of Mental Health Services in Primary Care Settings, Depression Screening and Follow-up Care
Beneficiary Engagement
Example Activity: Participation in a Qualified Clinical Data Registry (QCDR), Demonstrating Performance of Activities that Promote Implementation of Shared Clinical Decision-Making Capabilities
Care Coordination
  Example Activity: Timely Communication of Test Results Defined as – Timely Identification of Abnormal Test Results with Timely Follow-up
Emergency Response & Preparedness
  Example Activity: Participation in Disaster Medical Teams, Domestic or International Humanitarian Volunteer Work
Expanded Practice Access
  Example Activity: Expanded Hours in the Evenings/Weekends with Access to the Patient Medical Record
Patient Safety & Practice Assessment
  Example Activity: Maintenance of Certification Part IV, Annual Registration and Participation in the Prescription Drug-Monitoring Program of the State Where You Practice
Population Management
  Example Activity: Participation in Center for Medicare & Medicaid Innovation (CMMI) Models such as The Million Hearts Campaign

You can view a full list of available Improvement Activities by going downloading our 2017 MIPS Improvement Activities Guide, or by visiting the Quality Payment Program website ( Keep in mind when reviewing the list that there may be activities your practice or clinicians have already implemented or some that would be easy to implement.

Improvement Activities can be attested to through a Qualified Registry, QCDR, EHR, or the CMS GPRO web-interface (for groups of 25 or more). For any improvement activity, you select, you need to be prepared to prove that you have done the activity if audited by CMS. The QPP website has a document titled “MIPS Data Validation Criteria” that lists the type of documentation you would be expected to supply to CMS in case of an audit.

Still confused or need assistance reviewing which activities may be appropriate for your practice? You can download our 2017 MIPS Improvement Activities Guide for a complete list of activities and a questionnaire to help identify which activities you may be eligible for. You can also contact one of our knowledgeable Consultants to help guide you successfully through your first MIPS submission.



Your Guide to the 2017 MIPS Improvement Activities Category

Navigating the Improvement Activities performance category can be a struggle. Download our exclusive guide to ease the burden and help you succeed!

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