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  • MIPS Manual 2017—Know the Basics: 5 Key Steps for Improvement Activities and ACI

    By Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Molly Peltzman, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content was excerpted from EyeNet’s MIPS Manual 2017.


    1. New users, sign up as soon as possible—and no later than Oct. 31—to use the IRIS Registry web portal for manual MIPS reporting. Improvement activities and ACI measures can only be reported manually. Go to aao.org/iris-registry and click “Sign Up.”

    2. Start performing improvement activities and ACI measures. Don’t wait until the last possible day—Oct. 2, 2017—before starting your 90-day performance periods for these 2 performance categories.

    3. Document your performance so that you’ll be ready for a future audit. Download Table 7 (PDF) and Table 8 (PDF) for CMS’ suggestions for how you should document the 22 improvement activities that can be reported via the IRIS Registry web portal. CMS also plans to publish documentation suggestions for ACI measures and has said that it will post them at https://qpp.cms.gov/about/resource-library.

    4. Report your improvement activities and ACI measures via the IRIS Registry web portal. You must finish entering your data for improvement activities and ACI into the IRIS Registry web portal no later than Jan. 15, 2018.

    5. Submit a signed data-release consent form. Do this no later than Jan. 15, 2018. Each MIPS participant in your practice must submit a new consent form each year. One release form covers all 3 performance categories. Your consent form allows the Academy to send your attestation information to CMS.

    For more information on the IRIS Registry, visit aao.org/iris-registry and talk to the Academy staff at AAO 2017.

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    Next: Know the Basics: Quality Overview

    Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    COPYRIGHT© 2017, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry are trademarks of the American Academy of Ophthalmology®.