• MIPS 2021—Improvement Activities: Select, Perform, and Document Your Activities

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


    MIPS includes 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 62 improvement activities that are most meaningful for ophthalmology practices (see “Table: 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 “How You Will Be Scored”).

    Some improvement activities were designed for QCDRs, such as the IRIS Registry. The improvement activities 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) 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 or see the IRIS Registry guide at aao.org/iris-registry/maintenance-of-certification.

    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. When groups perform an activity, each clinician can choose his or her own 90-day period within the 2021 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 for all the activities that can be reported via the IRIS Registry, 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. In 2019, 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: How to Report Activities

    Next: Table: Improvement Activities at a Glance 

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