MIPS Improvement Activities Component

The MIPS Improvement Activities performance category rewards eligible clinicians (ECs) 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 score in performance year 2020 and beyond. Most anesthesiologists and their groups will attest to the MIPS Improvement Activities category via a Qualified Registry, a Qualified Clinical Data Registry or though the Quality Payment Program website.

CMS has finalized a list of 104 activities for the 2020 reporting year. The list of MIPS Improvement Activities and their data validation requirements are available in the Quality Payment Program Resource LibraryEach 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. For group practices reporting in 2020, 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.  

CMS 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. 

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