MIPS Improvement Activities Component

Improvement Activities is a scored category of MIPS that aims to reward eligible clinicians and groups for engaging in clinical practice improvement activities, such as care coordination, beneficiary engagement and patient safety. Improvement Activities account for 15% of the total MIPS Composite Score in performance year 2017 and beyond.

CMS has finalized a list of 92 activities for the 2017 reporting year. The list of 92 measures and their descriptions is available on the Quality Payment Program website. 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 must receive a score of 40 points.

The Final Rule offers two exceptions to this point structure:

  • Eligible clinicians participating in MIPS APMs will receive the equivalent of the base score of 40 points for this component.
  • 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. They will still be required to reach 40 points to receive full credit for this component.

Eligible clinicians and their practices may report (either as individuals or as a group practice) via Attestation, Qualified Clinical Data Registry (QCDR), Qualified Registry, Electronic Health Record (EHR) or CMS Web Interface (groups of 25+). Eligible clinicians and their practices should note that the Improvement Activities category is separate from the improvement activities bonus points that an eligible clinician may qualify for under the Advancing Care Information performance category.

You can also find CMS Resources here and ASA FAQs here for all things MACRA.