The following questions and responses for the MIPS Improvement Activities performance category are based upon the 2021 Quality Payment Program (QPP) Final Rule and previous finalized regulation.
1. How many of the total MIPS points is the MIPS Improvement Activities performance category worth?
The MIPS Improvement Activities performance category accounts for 15% of the total MIPS score in performance year 2021. There are no exemptions to reporting this performance category.
2. Where can I find the improvement activities and their validation criteria?
CMS has finalized 105 activities for the 2021 reporting year. The list of MIPS Improvement Activities and their data validation requirements are available in the Quality Payment Program Resource Library. Improvement activities and their validation criteria may change from year-to-year so it is important that individuals and groups review current year information.
3. How many improvement activities must I report?
Each individual improvement activity is assigned a weight of either medium or high. Medium weighted activities receive 10 points and high weighted activities receive 20 points. To receive full credit, eligible clinicians and groups must receive a score of 40 points.
Small practices, rural practices, or practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS eligible clinicians will have their medium weighted activities count for 20 points and their high weighted activities count for 40 points. Those ECs and groups will still be required to reach 40 points to receive full credit for this component.
If you’re a clinician in any Alternative Payment Model (APM) who is participating in traditional MIPS, you’ll earn half credit (50%) automatically for the improvement activities performance category
Eligible clinicians participating in APM Performance Pathway will receive the equivalent of the base score of 40 points for this component.
4. How do I submit data for the improvement activities performance category?
Eligible clinicians and groups may attest that the improvement activity was completed through a qualified clinical data registry, a qualified registry, a third-party vendor or the CMS Quality Payment Program website. Individuals and groups should retain documentation that the activity was completed. The documentation must meet data validation requirements that are available in the Quality Payment Program Resource Library. Groups should maintain that documentation for at least six years.
5. Can CMS or other entity audit my improvement activity attestation?
Yes. As with the MIPS Quality performance category, the attestation and data you submit must be true, accurate and complete. CMS requires that third-party vendors in the Quality Payment Program conduct random audits to ensure the practice has documentation in support of the attestation. CMS may also audit or request documentation that supports your improvement activities attestation(s).
6. How many people in my group need to participate in an improvement activity?
For group practices reporting in 2021, CMS requires 50% of the group’s National Provider Identifier (NPI) clinicians to perform the same improvement activity during any continuous 90-day period within the same performance year. Note that the requirement is for 50% of all the clinicians in the group, not just those who may be MIPS-eligible.
7. Do 50% of my group’s NPIs have to complete the improvement activity for the same 90-day period?
No. The group may stagger the improvement activity over the course of the performance year. However, the group should maintain documentation on when each NPI started or finished the same improvement activity.
8. I already conduct quality improvement activities at my local facility. Can I just attest that I completed a QI project?
No. ECs and groups may only attest to an improvement activity that is recognized by CMS. CMS has finalized 105 activities for the 2021 performance year. The list of MIPS Improvement Activities and their data validation requirements are available in the Quality Payment Program Resource Library. Individual ECs and groups should maintain appropriate documentation demonstrating that they have completed the improvement activity for the dates of their attestation.