• MIPS 2018—Overview 3: The Improvement Activities Performance Category

    Written By: Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content was excerpted from EyeNet’s MIPS 2018; also see the Academy’s MIPS hub page

    Select your reporting mechanism. The Academy recommends that you use the IRIS Registry web portal to manually attest that you performed your improvement activities. Your other options are to attest via the CMS web portal or via your EHR vendor.

    Reporting at a Glance

    The minimum performance period is 90 consecutive days. Like promoting interoperability (formerly ACI), this performance category has a minimum performance period of 90 days—but you don’t have to use the same 90-day period for both performance categories.

    To get the maximum score, you must perform and report 1 to 4 improvement activities. The number of activities depends on how they’re weighted, and on the size and location of your practice (see “Scoring Summary,” below).

    If you use EHR, go for the promoting interoperability (formerly ACI) bonus for using CEHRT for improvement activities. Certain activities not only contribute to your improvement activities score but also can boost your PI score if performed using certified EHR technology (CEHRT) functionalities.

    A yes/no approach to reporting improvement activities. To score points for an activity, affirm (yes) that you successfully performed that activity for at least 90 consecutive days.

    Consider the Maintenance of Certification (MOC) Part IV improvement activity. If you have integrated your EHR system with the IRIS Registry, you can work with the American Board of Ophthalmology (ABO) to earn credit for both MIPS and MOC.

    In case of a future audit, document performance of your improvement activities. For documentation suggestions, visit aao.org/medicare/improvement-activities.

    Scoring Summary

    How many points do you get for an activity? It depends on how the activity is weighted (and whether you’re able to double the score). If the activity weight is:

    • Medium—10 points (double score: 20 points)
    • High—20 points (double score: 40 points)

    Who scores double? Those who are:

    Maximum score is 40 points. A small practice could max out by successfully performing and reporting 1 high-weighted activity.

    Calculating your improvement activities score (0%-100%). CMS divides your total number of points by 40 and turns the resulting fraction into a percentage. For example, if you get 30 points, your improvement activities score would be 75%.

    Your improvement activities score (0%-100%) contributes up to 15 points to your MIPS final score. For example, if your improvement activities score is 75%, it would contribute 11.25 points.

    Want to know more about improvement activities? See How to Report Improvement Activities, starting with How You’ll Be Scored.


    Previous: Overview 2: The Promoting Interoperability (Formerly ACI) Performance Category.

    Next: Overview 4: The Cost Performance Category.

    Note: 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© 2018, 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 are trademarks of the American Academy of Ophthalmology®.