This content was excerpted from EyeNet’s MIPS Manual 2017.
Table 3: Improvement Activities Overview
Decide whether to participate in MIPS as an individual or as part of a group. You will need to participate in the same way—as an individual or as part of a group—for all MIPS performance categories. There are pros and cons to each approach. (See “The Pros and Cons of Group Reporting.”)
Pick your reporting mechanism. You can attest to your improvement activities performance via the CMS web portal, EHR vendor, or the IRIS Registry web portal.
Reporting at a Glance
The minimum performance period is 90 consecutive days. In 2017, the improvement activities, ACI, and quality performance categories each have a minimum performance period of 90 days—but you don’t have to use the same 90-day period for all 3 categories.
To get the maximum score, you must perform and report 1 to 4 improvement activities. The number of activities depends on how they’re weighted, and on the size and location of your practice (see “Scoring Summary,” below).
If you use EHR, go for the ACI bonus for using CEHRT for improvement activities. Certain activities not only contribute to your improvement activities score but also can boost your ACI score if performed using a certified EHR technology (CEHRT).
A yes/no approach to reporting improvement activities. To score points for an activity, affirm (yes) that you successfully performed that activity for at least 90 consecutive days.
In case of a future audit, document performance of your improvement activities. For each activity, CMS has published examples of acceptable documentation. To view these examples, download Table 8 (PDF).
How many points do you get for an activity? It depends on how the activity is weighted (and whether you’re able to double the score). If the activity weight is:
- Medium—10 points (double score: 20 points)
- High—20 points (double score: 40 points)
Who scores double? Those who are:
- in small practices (< 16 MIPS eligible clinicians)
- in practices in geographic health professional shortage areas (HPSAs)
- non–patient-facing MIPS participants
Maximum score is 40 points. So a small practice could max out by reporting 1 high-weighted activity.
Calculating your improvement activities score (0%-100%): CMS divides your total number of points by 40 and turns the resulting fraction into a percentage. For example, if you get 30 points, your ACI score would be 75%. This is your improvement activities score.
Your improvement activities score (0%-100%) contributes up to 15 points to your MIPS final score. For example, if your improvement activities score is 75%, it would contribute 11.25 points.
For a deeper dive, see “Improvement Activities: Know the Essentials.”
Next: Know the Basics: Advancing Care Information (ACI) Overview
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