• MIPS 2020—Improvement Activities: Overview

    This content is excerpted from EyeNet’s MIPS 2020; also see the Academy’s MIPS hub page.


    You should decide how you will report improvement activities, understand how to score 100% for the performance category, and then select, perform, and document your improvement activities for 2020. Start with this quick overview.

    Default weight in MIPS final score: 15%

    Performance period: Typically, at least 90 continuous days.

    How to score 100%: Practices with a special status—such as small or rural practices—should perform one high-weighted activity or two medium-weighted activities. Other practices should perform two high-weighted activities or one high-weighted and two medium-weighted activities or four medium-weighted activities.

    Document your performance: Make sure you include dates.

    New for 2020: More reporting needed for groups. In 2020, practices that report as a group will only score points for an improvement activity if at least 50% of the practice’s clinicians meet the reporting requirements of that activity (e.g., in a practice of nine, at least five). They must do each activity for a performance period of at least 90 consecutive days, but they don’t all have to do it during the same date range. (In 2019, by contrast, only one of the group’s clinicians needed to perform the activity.)

    New for 2020: CMS has removed some improvement activities. CMS has removed 15 activities, including five that you could report via the IRIS Registry in 2019:

    • IA_AHE_4: Leveraging a QCDR for use of standard questionnaires
    • IA_CC_4: TCPI Participation
    • IA_CC_6: Use of QCDR to promote standard practices, tools, and processes in practice for improvement in care coordination
    • IA_PM_10: Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
    • IA_PSPA_5: Annual registration in the Prescription Drug Monitoring Program

    New for 2020:  CMS makes substantive changes to IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements. CMS removed several QCDR-related improvement activities (see above) and incorporated them into IA_PSPA_7.

    Update June 2020:  In Spring 2020, after EyeNet's MIPS Manual had gone to press, CMS announced a new high-weighted improvement activity, IA_ERP_3: COVID-19 Clinical Trial. You may attest to this improvement activity if you treat patients diagnosed with COVID-19 and report their data to a Qualified Clinical Data Registry (QCDR), such as the IRIS Registry.

    Previous: Table: Promoting Interoperability Scoring Methodology (Example)

    Next: Improvement Activities: How You Will Be Scored

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