• MIPS Manual 2017—Improvement Activities: Know the Essentials

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

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


    Will you score full marks for the improvement activities performance category? To do so, you will need to successfully perform 1 to 4 performance activities—the amount depends on how those activities are weighted, as well as the size and location of your practice. You need to perform each activity for at least 90 consecutive days. Your score for improvement activities contributes up to 15 points to your 2017 MIPS final score.

    How You’ll Be Scored

    How many points do you get for an improvement activity? This depends on (1) how the activity is weighted and (2) whether you’re able to double the score.

    If an activity’s weight is:

    • medium—it scores 10 points (double score is 20 points)
    • high—it scores 20 points (double score is 40 points)

    Who scores double? MIPS participants can score double for an improvement activity if they are:

    • in a small practice (fewer than 16 MIPS eligible clinicians),
    • in a rural practice,
    • in a practice that is in a geographic health professional shortage area (HPSA), or
    • non–patient-facing MIPS clinicians.

    Are you a non–patient-facing clinician? Few ophthalmologists are likely to fall within this category. You are designated a non–patient-facing MIPS clinician if you bill Medicare for no more than 100 patient-facing encounter codes in a designated period.

    For group reporting, if more than 75% of the NPIs who bill under the group’s TIN during are non–patient-facing, then the group as a whole is considered non–patient-facing.

    Maximum score is capped at 40 points. If you don’t score double, you can accrue the maximum score of 40 points by performing either:

    • 4 medium-weighted activities (4 × 10 points)
    • 2 medium-weighted activities (2 × 10 points) and 1 high-weighted activity (1 × 20 points), or
    • 2 high-weighted activities (2 × 20 points).

    If you are eligible to score double, you can accrue 40 points by performing:

    • 2 medium-weighted activities (2 × 20 points) or
    • 1 high-weighted activity (1 × 40 points).

    Each improvement activity is all or nothing. You won’t score points for an improvement activity unless it is performed for 90 days and you satisfy all of its requirements. You do not score partial credit for partially reporting an activity.

    Some MIPS participants will automatically get credit. MIPS eligible clinicians (and groups) who are practicing as part of an accredited patient-centered medical home will automatically score 40 points (the maximum score); those who are participating as part of an alternative payment model (APM) will automatically score a minimum of 20 points (half the maximum score). Few ophthalmologists are expected to fall within these 2 categories in 2017.

    Your improvement activities score (0-40) points is turned into a percentage, which contributes up to 15 points to your MIPS final score. CMS divides your total number of points by 40 and turns the resulting fraction into a percentage (e.g., a score of 20 points would be 50%). This contributes up to 15 points to your MIPS final score (e.g., a score of 50% would contribute 7.5 points).

    Decide How You Will Report

    Select a reporting mechanism. You can attest to your improvement activities performance via the IRIS Registry, the CMS web portal, or possibly your electronic health record (EHR) vendor (ask your vendor if it offers this option).

    Attest that you successfully completed improvement activities. Whichever reporting mechanism you choose, it is your responsibility to attest that you appropriately completed the improvement activities that you choose to perform. If that mechanism is run by a third party (e.g., the IRIS Registry), the third party simply reports CMS what you attested—the third party is not confirming that you did in fact complete those improvement activities. You also should document your performance of those activities so you’ll be prepared for a possible audit in the future.

    Consider reporting as a group. You report improvement activities either as an individual or as a group. When you report as a group, all MIPS eligible clinicians who participate in that group will receive the same score for improvement activities. And if at least 1 of those clinicians satisfies the requirements for a particular improvement activity, then the whole group can score points for that activity. Keep in mind that you must participate in MIPS in the same way—either as an individual or as a group—for all MIPS performance categories.

    Select, Perform, and Document Your Improvement Activities

    The MIPS regulations lists more than 90 improvement activities, but many of them aren’t suitable for ophthalmologists.

    Which improvement activities are most relevant to ophthalmology? The IRIS Registry supports reporting of the 22 improvement activities that are most meaningful for ophthalmology practices. These include 5 high-weighted activities and 17 medium-weighted activities (see the Academy’s online list of improvement activities or download Table 7 [PDF]).

    Select which improvement activities you will perform. In order to score full marks, the number of improvement activities that you need to perform can range from 1 to 4, depending on the activities’ weights and whether you score double (see “How You’ll Be Scored,” above).

    Consider the ACI bonus for using CEHRT. When selecting improvement activities, you should note that some of them can earn you a bonus for your ACI score if you use a certified EHR technology (CEHRT) to help you perform those activities (see Table 7, which is a downloadable PDF). For example, suppose you decide to perform the “Provide 24/7 access” improvement activity (see first activity in Table 7); if you use your CEHRT’s secure messaging functionality to provide 24/7 access for advice about urgent and emergent care (e.g., sending or responding to secure messages outside business hours), this would qualify you for the 10% CEHRT for improvement activities bonus. You only need to use CEHRT for 1 improvement activity to score the full 10% bonus. This bonus accrues to your ACI score, not your improvement activities score.

    Some improvement activities involve integrating your EHR system with the IRIS Registry. If you fully integrate your EHR system with the IRIS Registry and utilize its dashboard, you could qualify for activities that involve or include the use of a registry. These are flagged in Table 7 (PDF), an at-a-glance chart.

    CMS has stated that “If you choose to participate in MIPS via a QCDR [such as the IRIS Registry], you must select and achieve each improvement activity separately. You will not receive credit for multiple acitivities just by selecting one activity that includes participation in a QCDR.”

    The MOC Part IV improvement activity shows promise. If you integrate your EHR with the IRIS Registry, you may be able to meet the requirements of this activity while working on your maintenance of certification. At time of press, the American Board of Ophthalmology was running a pilot program in which its diplomates would analyze their IRIS Registry data to identify areas for improvement, set specific goals, and specify what steps would be taken to achieve those goals. After implementing those steps, diplomates would review their IRIS Registry data to see if quality of care had improved. For more information, see this activity’s listing in Table 8 (PDF), a downloadable chart.

    You must perform improvement activities for at least 90 consecutive days. In order to score points for an improvement activity, you—or another clinician within your group, if you are reporting as a group—must perform that activity for at least 90 consecutive days.

    The MIPS regulations state: “Activities, where applicable, may be continuing (that is, could have started prior to the performance period and are continuing) or be adopted in the performance period as long as an activity is being performed for at least 90 days during the performance period.”

    Document your improvement activities. To make sure you’re ready for a future audit, you should maintain documentation that shows you performed the improvement activities that you are claiming credit for. CMS has suggested appropriate documentation for each activity (download Table 8 [PDF] and see the suggested documentation).

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