This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page.
The MIPS regulations include more than 100 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 34 improvement activities that are most meaningful for ophthalmology practices (see Table 13: Improvement Activities at a Glance).
Select which activities you will perform. To score 100% on this performance category, the number of improvement activities that you need to perform can range from one to four, depending on the activities’ weights and whether you score double (see Improvement Activities: An Overview).
If you have integrated your EHR system with the IRIS Registry, consider these six improvement activities. IRIS Registry–EHR integration facilitates performance of several activities. These include one high-weighted activity:
And five medium-weighted activities:
CMS states, “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 activities just by selecting one activity that includes participation in a QCDR.”
You must perform improvement activities for at least 90 consecutive days. In order to score points for an improvement activity, you—or one of your colleagues, if you are reporting as part of a group or virtual 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. Ensure that you’re ready for a future audit by maintaining documentation that shows you performed the improvement activities for which you are claiming credit. CMS has published suggested documentation for each improvement activity (go to Table 13: Improvement Activities at a Glance and click on an activity’s title for a link to a detailed web page that lists CMS’ documentation suggestions).
In case of an audit, can you prove that improvement activities were performed for at least 90 days? When you document your performance of improvement activities, make sure you include dates so you can prove that you performed the activities for at least 90 days. You should maintain this documentation for at least six years.
Note: In June 2019, CMS announced its first-ever MIPS audits. This summer, you may receive—either by email or certified mail—a request for information from the 2017 or 2018 MIPS performance years. Guidehouse, a CMS contractor, is conducting data validation and audits on a sample of MIPS eligible clinicians. If you receive such a request, please contact the Academy at mips@aao.org.
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