• MIPS 2018—Improvement Activities: Select, Perform, and Document Your Activities

    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


    You can use the same improvement activities that you used in 2017. 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 24 improvement activities that are most meaningful for ophthalmology practices. These include 5 high-weighted activities and 19 of medium weight (see Table 17 [PDF], or view the measures online). 

    Select which activities you will perform. In order to score full marks, the number of improvement activities that you need to perform can range from 1 to 4, depending on the activities’ weights and whether you score double (see How You’ll Be Scored).

    If your EHR system is a CEHRT, go for the promoting interoperability (PI; formerly ACI) bonus. When selecting improvement activities, you should note that some of them can earn you a bonus for your PI score if you use the functionalities of a certified EHR technology (CEHRT) to help you perform those activities (see Table 17 [PDF] or view them online).

    For example, suppose you decide to perform the Provide 24/7 access improvement activity; if you use your CEHRT’s secure messaging functionality to provide 24/7 access for advice about urgent and emergent care (e.g., sending or responding to secure messages outside business hours), this would qualify you for the 10% PI bonus.

    You only need to use CEHRT for 1 improvement activity to score the full 10% PI bonus. This bonus accrues to your PI score, not your improvement activities score.

    Some improvement activities involve integrating your EHR system with the IRIS Registry. If you fully integrate your EHR system with the IRIS Registry and utilize its dashboard, you could qualify for activities that involve or include the use of a registry (see Table 17 [PDF]).

    CMS has stated that “If you choose to participate in MIPS via a QCDR [such as the IRIS Registry], you must select and achieve each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR.”

    Are you already performing MIPS improvement activi­ties? There are several improvement activities that practices may have been performing and documenting as a matter of course. These include the following:

    You must perform improvement activities for at least 90 consecutive days. In order to score points for an improve­ment activity, you—or one of your colleagues, if you are reporting as part of a group or virtual group—must perform that activity for at least 90 consecutive days. The MIPS regulations state: “Activities, where applicable, may be continuing (that is, could have started prior to the performance period and are continuing) or be adopted in the performance period as long as an activity is being performed for at least 90 days during the performance period.”

    Document your improvement activities. To make sure you’re ready for a future audit, you should maintain doc­umentation that shows you performed the improvement activities. (For documentation suggestions, see aao.org/medicare/improvement-activities.)

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    Previous: Improvement Activities: Decide How You Will Report.

    Next: Improvement Activities: Get Credit for MIPS and MOC.

    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.

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