• MIPS 2020—Improvement Activities: Select, Perform, and Document Your Activities

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


    Select, Perform, and Document Your Activities

    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 77 improvement activities that are most meaningful for ophthalmology practices.

    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 “How You Will Be Scored”). 

    Some improvement activities were designed for QCDRs, such as the IRIS Registry. The improvement activity performance category seeks to leverage the capability of qualified clinical data registries (QCDRs). For example, IRIS Registry–EHR integration facilitates performance of these activities:

    Get credit for MIPS and MOC. You can design and implement a quality improvement project that meets the requirements of the medium-weighted Maintenance of Certification (MOC) Part IV improvement activity. But you will need to submit your proposed project to the American Board of Ophthalmology (ABO) no later than Aug. 31 for its approval. For further information, visit the ABO’s website at https://abop.org/IRIS.

    The performance period is typically 90 days. In order to score points for an improvement activity, you—or at least 50% of your colleagues, if you are reporting as part of a group or virtual group—must perform that activity for the performance period, which is typically at least 90 consecutive days. Check the improvement activity specifications to see if it is an exception to the 90-day rule.

    Some performance period flexibility for group reporting. First the bad news. Whereas in 2019 a group would get credit for an improvement activity if just one of its clinicians performed it, in 2020 at least 50% of the group’s clinician must do so. Fortunately, those clinicians don’t have to perform the activity during the same 90-day date range; each clinician can choose his or her own 90-day period, provided it takes place during the 2020 calendar year. 

    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 (for detailed web pages that list CMS’ documentation suggestions, go to aao.org/medicare/improvement-activities).

    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. Last summer, Guidehouse, a CMS contractor, started contacting practices to conduct the first ever MIPS audits. If you receive such a request, please contact the Academy at mips@aao.org.

    Previous: Improvement Activities: Decide How You Will Report

    Next: Table: Improvement Activities at a Glance

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