This content is excerpted from “MIPS 2023, Part 2” (EyeNet, February 2023). EyeNet’s MIPS content, including its MIPS 2023 supplement, is being published online ahead of print as it becomes available.
The improvement activities performance category is largely the same as in previous years, though some activities have been removed and others have been revised, and CMS is considering an Academy proposal to increase the inventory of activities that can be reported via the IRIS Registry.
Improvement Activities Recap
Each improvement activity has either a high or a medium weighting.
If you are in a practice with a special status (such as a small or rural practice), you can earn an improvement activities score of 100% by successfully performing one high-weighted improvement activity or two medium-weighted ones.
If, however, your practice doesn’t have that special status, a score of 100% would involve performing two high-weighted activities or one high- and two medium-weighted activities or four medium-weighted activities.
How do you know whether your practice has a special status? Use the QPP Participation Status Lookup Tool at https://qpp.cms.gov/participation-lookup.
Do You Plan to Repeat Your 2022 Improvement Activities?
Are you planning to repeat the same improvement activities that you performed last year?
Before finalizing that plan, wait to see what improvement activities that will be newly available for reporting via the IRIS Registry in 2023 (see below). You also should know that some of the activities that you could report via the IRIS Registry in 2022 are no longer available, and some of the remainder have undergone significant revisions. (Note: Most improvement activities can be repeated in consecutive years, but there are some exceptions. For example, IA_PSPA_22 can only be reported once every four years. This activity involves completing a CDC course on prescribing opioids. Similarly, IA_PSPA_4, which involves a survey on patient safety culture, can only be reported every four years.)
Three improvement activities can no longer be reported via the IRIS Registry. CMS eliminated the following improvement activities:
- IA_PM_7: Use of QCDR [Qualified Clinical Data Registry] for feedback reports that incorporate population health. CMS removed this activity because it is consolidating this and two other QCDR-related improvement activities into IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements. (However, IA_PM_7 has a high weighting and IA_ PSPA_7 has only a medium weighting.)
- IA_PSPA_6: Consultation of the Prescription Drug Monitoring Program (PDMP). CMS removed this activity because it is duplicative of the Query of PDMP promoting interoperability measure.
- IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes. CMS removed this activity because it is duplicative of the revised IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes.
A new name, new emphasis, and new description for some improvement activities. Improvement activities that underwent major changes include the following:
- IA_CC_13 has a new name and a revised description that makes alignment with the OpenNotes initiative (opennotes.org) mandatory rather than optional when performing this improvement activity.
- Old name—IA_CC_13: Practice improvements for bilateral exchange of patient information
- New name—IA_CC_13: Practice improvements to align with OpenNotes principles
- IA_CC_14 has a new code (IA_AHE_ 12), a new name, and a revised description. It also is being moved from the care coordination subcategory to the achieving health equity subcategory.
- Old code and name—IA_CC_ 14: Practice improvements that engage community resources to support patient health goals
- New code and name—IA_AHE_ 12: Practice improvements that engage community resources to address drivers of health
IA_CC_13 and IA_AHE_12 are medium- and high-weighted improvement activities, respectively.
CMS revised several improvement activities. CMS revised the activity descriptions of the following:
- IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements. CMS absorbed three other QCDR-based improvement activities into this one activity and expanded its description accordingly. IA_PSPA_7 is a medium-weighted activity.
- IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes. CMS changed part of the activity’s description from “all staff participates in improvement activities” to “all staff, including leadership, participates in improvement activities.” IA_PSPA_19 is a medium-weighted activity.
See What's Been Added to the IRIS Registry’s Inventory of Improvement Activities
In 2023, 66 improvement activities can be reported via the IRIS Registry, which is 10 more than last year. The Academy will post their full CMS descriptions at aao.org/medicare/improvement-activities.
High-weighted activities. Consider the following four activities:
- IA_AHE_8: Create and implement an antiracism plan. Create and implement a plan using antiracism tools, such as the CMS Disparities Impact Statement, which can be downloaded at www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Disparities-Impact-Statement-508-rev102018.pdf.
- IA_AHE_11: Create and implement a plan to improve care for lesbian, gay, bisexual, transgender, and queer patients. Understand and address health disparities for these populations of patients.
- IA_BE_25: Drug cost transparency. Counsel patients about the cost of medications using a real-time benefit tool that provides real-time, patient-specific formulary and benefit information for drugs, including cost-sharing.
- IA_EPA_6: Create and implement a language access plan. Create a plan to address communication barriers for patients who have limited English proficiency. The plan should align with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (https://thinkculturalhealth.hhs.gov/clas).
Medium-weighted activities. Review these six additional activities:
- IA-AHE_9: Implement food insecurity and nutrition risk identification and treatment protocols. Identify and provide appropriate support to 1) patients with or at risk of food insecurity or 2) patients with or at risk of poor nutritional status. (CMS points out that poor nutritional status can apply to people who are overweight as well as those who are underweight.)
- IA_AHE_10: Adopt Certified Health Information Technology for security tags for electronic health record data. This involves use of an EHR system’s security labeling services.
- IA_ERP_4: Implementation of a personal protective equipment (PPE) plan. Implement a plan to acquire, store, maintain, and replenish supplies of PPE for clinicians and staff who are in physical proximity to patients.
- IA_ERP_6: COVID-19 vaccine achievement for practice staff. Make sure that all staff—except for those who have a medical contraindication—are up to date with COVID vaccines as recommended by the CDC (www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html).
- IA_PM_18: Provide clinical-community linkages. This activity involves providing “a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency” using health information technology along with “quality measurement and improvement processes.” CMS has indicated that you could meet the requirements of this activity if you satisfy the criteria of the Patient-Centered Connected Care Recognition Program (www.ncqa.org/programs/health-care-providers-practices/patient-centered-connected-care-pccc/).
- IA_PSPA_15: Implementation of an ASP. Implement an antimicrobial stewardship program (ASP) that measures the appropriate use of antibiotics for several different conditions.
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