Skip to main content
  • MIPS 2021—Improvement Activities: How to Report Activities

    This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.


    Decide how you will attest. You can attest to your improve­ment activities performance via the IRIS Registry, the CMS QPP portal, or possibly your EHR vendor (ask your vendor whether it offers this option and what fees are involved).

    Attest that you successfully completed improvement ac­tivities. However you decide to attest, it is your responsibility to attest that you appropriately completed the improvement activities that you choose to perform. If you attest via 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.

    Group-level reporting. 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.

    Previous: How You’ll Be Scored

    Next: Select, Perform, and Document Your Activities 

    DISCLAIMER AND LIMITATION OF LIABILITY: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    COPYRIGHT© 2021, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.

    All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).