A Closer Look at MIPS Improvement Activities

Share this Article

closer look at MIPSMACRA (The Medicare Access and CHIP Reauthorization Act of 2015) may be well underway, but many practices are still unsure about many details of the quality payment program; such as which program to select, which improvement activities to choose, and when to get started.

Under MACRA, clinicians will choose which program they participate in depending on their size, specialty, location or patient population. Below are the two options:

According to CMS, 83-90% of eligible clinicians will fall into the MIPS track in 2017, and 10-17% will fall into the AAPM track. While provider payment will not be impacted through the program until Jan 1, 2019, CMS is using 2017 as the performance year for determining clinician payment adjustments in 2019.

Under the MIPS reporting program, there are four performance categories that each hold a value which will total the MIPS Composite Performance Score; quality, clinical practice improvement activities, advancing care information, and resource use.

  • Quality -60%
  • Advancing Care Information/Meaningful Use- 25%
  • Improvement Activities -15%
  • Cost -0% for 2017

Focusing on Improvement Activities for MIPS

The Improvement Activities performance category within MIPS assess a provider’s participation in activities that improve clinical practice, such as care coordination, shared decision making, patient safety practices, and expanding practice access.

The Improvement Activities Category is worth 15% of the total MIPS Performance Score. Under this category, clinicians will be able to choose from 94 activities to demonstrate their performance. Participants must attest to completing up to 4 improvement activities for a minimum of 90 days. (Small groups with less than 15 members or participants in rural areas must attest to completing 2 activities for a minimum of 90 days.)

Choosing Improvement Activities

The rule includes a list of 94 individual CPIAs (Clinical Practice Improvement Activities) divided into nine subcategories, proposed by CMS. Providers will choose from the activities listed under the Improvement Activity inventory on the Quality Payment Program website. The subcategories are listed below:

  1. Expanded Practice Access
  2. Population Management
  3. Care Coordination
  4. Beneficiary Engagement
  5. Patient Safety and Practice Assessment
  6. Participation in an APM
  7. Achieving Health Equity
  8. Integrating Behavioral and Mental Health
  9. Emergency Preparedness and Response

Submitting Improvement Activities

Providers should submit their improvement activities by attestation through the CMS Quality Payment Program website, a qualified clinical data registry, a qualified registry, or, when possible, from their electronic health record system. Eligible clinicians and groups only need to attest through the Quality Payment Program website that they completed the improvement activities selected or work with their vendor to determine the best way to submit their activities through a qualified clinical data registry (QCDR), a qualified registry, or their electronic health record system.

CMS encourages eligible clinicians to retain documentation for six years, as required by the CMS document retention policy.

How M3-Patient Experience® can help satisfy your Improvement Activities requirement

Medical practices that utilize M3-Patient Experience® satisfy the entire Improvement Activities category. The full 15% can be fulfilled through M3. Therefore, practices need to submit no further activities once utilizing M3-Patient Experience®.  

On-Demand Video Demo of M3 Patient Experience






Leave a Reply

Your email address will not be published. Required fields are marked *