pMD, a certified MIPS registry, makes understanding MIPS Improvement Activities scoring as easy as possible in Part 3 of the 4-Part series, MIPS Scoring, Simplified. In Part 1 of this series, we discussed the Basics of MIPS Scoring, and in Part 2, we discussed scoring for the Quality category. Today, we’ll discuss scoring for the Improvement Activities category. Then, in the series finale, Part 4, we’ll cover Advancing Care Information scoring, plus an overview of the MIPS payment adjustment calculation. So, without further ado, let’s talk Improvement Activities.

THE BASICS OF SCORING THE IMPROVEMENT ACTIVITIES CATEGORY

Improvement Activities scoring is, thankfully, much more straightforward than scoring for either Quality or Advancing Care Information. However, Improvement Activities is a completely new category, and unchartered territory can be confusing in and of itself. But, fear not, because when we boil Improvement Activities down to its essence, it’s a pass/fail category. So, as long as you are familiar with how the category applies to your particular situation, you should pass with flying colors.

SPECIAL GROUP ATTRIBUTES: SMALL GROUP, RURAL PRACTICE, HPSA, NON-PATIENT FACING

The maximum number of points available under Improvement Activities is 40. To earn the full 40 points, the first thing you’ll need to determine is how many improvement activities you or your group needs to submit to earn the full points. The number of activities you need to submit is determined by whether or not your group qualifies for special scoring. Four attributes result in special scoring for Improvement Activities:

1) small practice;

2) practicing in a health professional shortage area (HPSA);

3) practicing in a rural area; or

4) qualify as non-patient facing clinicians.

If any of these four attributes apply to you or your group, then your Improvement Activities category will be scored differently than groups that do not have one of these attributes. For special attribute groups only, each medium-weighted improvement activity is worth 20 points, and each high-weighted improvement activity is worth 40 points. That means, to earn the full 40 points, special attribute groups only have to submit:

• 1 high-weighted improvement activityor
• 2 medium-weighted improvement activities

To confirm whether one of these attributes applies to your group, head to the QPP website. Enter your NPI at this page, and a chart like this will appear:

You can see in the chart that this provider is considered a small group, but does not practice in a HPSA nor in a rural area, nor are they a non-patient facing provider. Note that all four of these attributes are the same for both the individual clinician (as listed under “For this clinician at this practice”) and the group practice (as listed under “For this practice”). This should always be the case - if they’re not, it’s worth a call to figure out why, since it’s possible CMS’s records are amiss. But, if any of these four attributes - small practice, rural, non-patient facing, or HPSA - says “yes”, then you can submit less improvement activities than larger practices, as discussed above.

STANDARD GROUPS

If none of these four special attributes apply to you, your chart on the NPI look up page will look similar to this:

Note that the four attributes relevant to Improvement Activities - non-patient facing, small practice, rural, and HPSA - all say “No.” This means you and your group qualify for standard Improvement Activities scoring, so each medium-weighted Improvement Activity is worth 10 points, and each high-weighted Improvement Activity is worth 20 points. Based on that, if you want to earn the full 40 points for this category, you have to submit:

• 2 high-weighted improvement activitiesor
• 4 medium-weighted improvement activitiesor
• 1 high-weighted improvement activity AND 2 medium-weighted improvement activities

REPORTING IMPROVEMENT ACTIVITIES

At the end of the performance period, you’ll attest to successful performance of your chosen improvement activities, for at least 90 days. So, using your submission mechanism, you’ll attest by indicating “Yes, I completed this improvement activity” or “No, I did not complete this improvement activity.” If you chose the correct number of improvement activities, and you positively attest to completing each activity, you’ll receive the full credit for the Improvement Activities category.

There are just a few more things to keep in mind about this category. First, you can’t earn bonus points for the Improvement Activities category. So, even if you submit more than your required activities, you’ll only receive 40 points. Second, everything outlined above applies to clinicians that are not participating in APMs. If you participate in some form of APM, then the rules for Improvement Activities are different for you. Third, many groups fret about what completing one of these activities actually means. Unfortunately, CMS is not giving a lot of guidance on this, and they don’t intend to give more. As far as I can find, there are only two decent sources of information to explain what each improvement activity requires. The QPP website’s improvement activities page, found here, and the “MIPS Data Validation Criteria” zip, which is available in the QPP Resource Library, found here. One helpful rule of thumb is to think about what documentation you or your group would point to if CMS ever audited your Improvement Activity attestation. If you feel confident that you have enough documentation to fully prove that you completed the specified activity, then you are in good shape.

Ok! See? I told you Improvement Activities scoring is easier! Now, stay tuned for Part 4, where we’ll discuss how the Advancing Care Information section is scored and how the final payment adjustment is determined. And as always, if you have any questions or would like to find out more about our MIPS registry, give us a call! To find out more about pMD's suite of products, which includes charge capture, secure messaging, and care coordination software and services, please contact pMD.

‍References:

‍Improvement Activities is a completely new category: “Improvement Activities: In this new performance category for 2017, clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety.” See https://qpp.cms.gov/mips/improvement-activities.

The maximum number of points available under Improvement Activities is 40: “To get the maximum score of 40 points for the Improvement Activity score…” See MIPS Improvement Activities Fact Sheet pdf, pg. 2, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf; seealso “To achieve the maximum score of 40 points for the Improvement Activity score…” See MIPS Improvement Activities Fact Sheet pdf, pg. 3, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf; see also 81 FR 77318, https://www.federalregister.gov/d/2016-25240/p-3758. (“[W]e are only requiring a total of 40 points to receive the highest score for the improvement activities performance category.”)

Four attributions indicate your group qualifies for special scoring, (1) if you are a small practice; (2) if you practice in a health professional shortage area (HPSA); (3) practice in a rural area; or (4) non patient facing clinicians: “For these clinicians [small groups, non-patient facing, rural area, or HPSA], each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and a high-weighted activity is worth 40 points of the total category score.” See MIPS Improvement Activities Fact Sheet pdf, pg. 3, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf

‍For special attribute groups only, each medium weighted improvement activity is worth 20 points, and each high weighted improvement activity is worth 40 points: “For these clinicians [small groups, non-patient facing, rural area, or HPSA], each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and a high-weighted activity is worth 40 points of the total category score.” See MIPS Improvement Activities Fact Sheet pdf, pg. 3, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf.

Standard Improvement Activities scoring means each medium weighted improvement activity is worth 10 points, and each high weighted improvement activity is worth 20 points: “Each medium-weighted activity is worth 10 points of the total Improvement Activity performance category score, and each high-weighted activity is worth 20 points of the total category score.” See MIPS Improvement Activities Fact Sheet pdf, pg. 3, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf.

For standard scoring, if you want to earn the full 40 points for this category, you have to submit 2 high weighted improvement activities, or 4 medium weighted improvement activities, or 1 high weighted improvement activity AND 2 medium weighted improvement activities: “Groups with more than 15 clinicians: Each activity is weighted either medium or high. To get the maximum score of 40 points for the Improvement Activity score, you may select any of these combinations: 2 high-weighted activities; 1 high-weighted activity and 2 medium-weighted activities; Up to 4 medium-weighted activities.” See MIPS Improvement Activities Fact Sheet pdf, pg. 2-3, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf.

To receive full credit, you must report successful performance of your chosen improvement activities for 90 days: “You must attest by indicating ‘Yes’ to each activity that meets the 90-day requirement (activities that you performed for at least 90 consecutive days during the current performance period).” See MIPS Improvement Activities Fact Sheet pdf, pg. 2, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf; see also 81 FR 77186, https://www.federalregister.gov/d/2016-25240/p-2387, (“we are finalizing at § 414.1360 that MIPS eligible clinicians or groups must perform improvement activities for at least 90 consecutive days during the performance period for improvement activities performance category credit.”)

So, using your submission mechanism, you’ll attest to completing your chosen improvement activities: “Eligible clinicians may submit their improvement activities by attestation via the CMS Quality Payment Program website, a qualified clinical data registry, a qualified registry, or, when possible, from their electronic health record system. Groups of 25 or more may choose to use the CMS Web Interface.” See MIPS Improvement Activities Fact Sheet pdf, pg. 2, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf.

You will receive the full points available for each improvement activity that you positively attest to completing: “In alignment with the reduction in total points required, we are finalizing that the following scoring that will apply to MIPS eligible clinicians who are a non-patient facing clinician, a small practice, a practice located in a rural area, or practice in a geographic HPSA or any combination thereof: *Reporting of one medium-weighted activity would result in 20 points or one-half of the highest score. *Reporting of two medium-weighted activities would result in 40 points or the highest score. *Reporting of one high-weighted activity would result in 40 points or the highest score. In alignment with the reduction in total points required, we are finalizing the following scoring that will apply to MIPS eligible clinicians who are not a non-patient facing clinician, a small practice, a practice located in a rural area, or a practice in a geographic HPSA: *Reporting of one medium-weighted activity would result in 10 points which is one-fourth of the highest score. *Reporting of two medium-weighted activities would result in 20 points which is one-half of the highest score. *Reporting of three medium-weighted activities would result in 30 points which is three-fourths of the highest score. *Reporting of four medium-weighted activities would result in 40 points which is the highest score. *Reporting of one high-weighted activity would result in 20 points which is one-half of the highest score. *Reporting of two high-weighted activities would result in 40 points which is the highest score. *Reporting of a combination of medium-weighted and high-weighted activities where the total number of points achieved are calculated based on the number of activities selected and the weighting assigned to that activity (number of medium-weighted activities selected × 10 points + number of high-weighted activities selected × 20 points). See 81 FR 77318, https://www.federalregister.gov/d/2016-25240/p-3758.

No bonus points are awarded in the Improvement Activities category: “The most any MIPS eligible clinician or group can achieve for the improvement activities performance category is 40 points, so if more activities are selected than, for example, 4 medium-weighted activities, the total points that could be achieved is still 40 points.” See 81 FR 77318, https://www.federalregister.gov/d/2016-25240/p-3770.

Participants in APMs have different Improvement Activity scoring than is outlined above: See MIPS Improvement Activities Fact Sheet pdf, pg. 3-4, available at https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf.

Unfortunately, CMS is not giving a lot of guidance on this, and they don’t intend to give more: “We are not planning to issue any more specific language around the activities for the transition. We kept it simple, and for the reason that we're just doing a simple adaptation. We aren't requiring any specific data to be submitted. So, for the transition year, what you find on the QPP website for the improvement-activities description is all that we're issuing at this point for the transition year.” See Webinar Transcript, held on 12/13/16, “Merit-Based Incentive Payment System (MIPS) Overview: Understanding Advancing Care Information (ACI) & Improvement Activities,” available at 2020 Promoting Interoperability Quick Start Guide

‍Participants should consider the documentation they have that support the chosen improvement activities, in case of audit: “So, for improvement activities, we're not exactly requiring documentation, but what we are telling providers is that you should retain copies of medical records, charts, reports, and any electronic data utilized, to determine which measures and activities were applicable and appropriate for their scope of practice, and patient population for reporting under MIPS for up to 10 years after the conclusion of the performance period, to prepare For verification in the event that you're selected for an audit. This record-retention timeframe aligns with the record-retention timeframes already in place for the APMs, either established in regulation or included in participation agreements. CMS may request any records or data retained for the purposes of MIPS for up to six years and three months. And we will provide audit specifications through subreg. guidance. And MIPS-eligible clinicians or groups selected for data validation audits will be provided instructions and examples of documents required.” See QPP MIPS Overview.