• MIPS 2017—Improvement Activities: Know the Essentials

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

    This Practice Perfect content is part of EyeNet’s Guide to MIPS 2017.

    Will you score full marks for your improvement activities? To do so, you will need to perform 1 to 4 improvement 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. Here are the details.

    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 participants.

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

    • 4 medium-weighted activities (4 × 10 points) or
    • 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 performing 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 a MIPS-eligible 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.

    Here’s how your improvement activities score contributes to your MIPS final score. CMS divides your total number of points by 40 and turns the resulting fraction into a percentage (e.g., if you have 20 points, your score would be 50%). This contributes up to 15 points to your MIPS final score (e.g., an improvement activities 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, a CMS website, or possibly your electronic health record (EHR) vendor (ask your vendor whether it will offer this option).

    You attest that you successfully completed improvement activities. Whichever reporting mechanism you choose, it is your responsibility to attest that you appropriately completed the 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 to CMS what you attested—the third party is not confirming that you did in fact complete those activities. Note: You also should document your performance.

    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. Note: 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 include 94 improvement activities, but many of them aren’t suitable for ophthalmologists.

    Which improvement activities are most relevant to ophthalmology? The IRIS Registry supports attestations for the 18 improvement activities that are most meaningful for ophthalmology practices. These include 5 high-weighted activities and 13 medium-weighted activities (see Table of Improvement Activities).

    Select which 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. When selecting improvement activities, you should note that some of them are eligible for an advancing care information (ACI) bonus if you use a certified EHR technology (CEHRT) to help you perform those activities (see Table of Improvement Activities). For example, suppose you decide to perform the “Provide 24/7 access” improvement activity (see first activity in table); 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 ACI bonus score. You only need to use CEHRT for 1 improvement activity to score the full 10% ACI bonus. This bonus accrues to your ACI score, not your improvement activities score.

    Score highly by integrating your EHR with the IRIS Registry. If you fully integrate your EHR system with the IRIS Registry and utilize its dashboard, you could qualify for 4 or 5 activities that involve or include the use of a registry (see Table of Improvement Activities). And if you use the IRIS Registry to complete Maintenance of Certification Part IV, you can qualify for an additional medium-weighted activity (see last activity in table).

    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.

    Improvement Activities’ Place Within MIPS

    Your 2017 MIPS final score determines whether your 2019 Medicare payments will be subject to a positive, negative, or neutral payment adjustment. You will score 0-100 points, based on your scores in 3 performance categories.

    Improvement activities score contributes up to 15 points to your MIPS final score. The improvement activities performance category is entirely new.

    Quality score contributes up to 60 points. The quality performance category replaces the Physician Quality Reporting System.

    Advancing care information (ACI) score contributes up to 25 points. The ACI performance category replaces the EHR meaningful use program.


    This content is excerpted from Part 4: How to Report Improvement Activities (Practice Perfect, April 2017 EyeNet), which is part of EyeNet’s Guide to MIPS 2017.  Part 4 includes Know the Essentials and 18 Improvement Activities That You Can Report Via the IRIS Registry.

    Note: This content was based on the information available at time of press; CMS is still publishing its regulatory guidance for MIPS.

    Use These Resources
    Academy MIPS resources include:

    Sign up for the IRIS Registry, which will be the tool of choice for MIPS reporting.