2018 What are Improvement Activities in MIPS?

What are Improvement Activities in MIPS?

The MIPS Improvement Activities performance category gauges your participation in activities that improve clinical practice, such as:

  • Ongoing care coordination
  • Clinician and patient shared decision making 
  • Regularly using patient safety practices 
  • Expanding practice access. 

In the 2018 performance period, MIPS eligible clinicians will be able to choose from 100+ activities to show their performance. The required performance period for the Improvement Activities performance category is at least a continuous 90-day period in 2018, up to and including the full calendar year (January 1, 2018, through December 31, 2018).

How Do I Pick Improvement Activities?

You should select a set of activities that are meaningful to your practice. You don’t have to pick activities from each of the 9 subcategories or from a certain number of subcategories. Review the complete list of Improvement Activities in the Practice Fusion MIPS Dashboard and select the appropriate number of activities to meet your practice’s MIPS submission goals. “Watch” those activities in the MIPS Dashboard Summary and mark as complete once you have met the activity’s minimum requirements.

The Centers for Medicare and Medicaid Services (CMS) added new improvement activities and updated some existing Improvement Activities for the 2018 MIPS performance period, including modifications to the improvement activities that qualify for a bonus in the Promoting Interoperability (PI, formerly Advancing Care Information) performance category. You’ll be able to pick from 100+ activities, separated into these 9 subcategories:

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

You can find all of the Improvement Activities eligible for use in MIPS Year 2 on the CMS Quality Payment Program website in the 2018 MIPS Improvement Activities inventory list.

What Do I Have to Report for Improvement Activity Performance in Year 2 (2018)?

The Improvement Activity performance category requires that you submit data to CMS indicating your attestation to completing a select number of activities during a specific performance period. The minimum amount of time you’ll need to complete the selected activities is 90 days. If you complete and submit attestation to select improvement activities, you may be eligible for a 10% bonus in the Promoting Interoperability (formerly the Advancing Care Information) performance category. The list of improvement activities that qualify for Promoting Interoperability bonus can be found in Appendix B of this CMS resource.

The table below outlines the reporting requirements based on the type of reporting you intend to use in 2018 or the type of provider you are.

Reporting Type

Requirement

Individual reporting for clinicians that are part of a small practice (less than 15 eligible clinicians)

Individual reporting for clinicians that are located in a rural area or HPSA

Individual reporting for non-patient facing clinicians


Each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score. Each high-weighted activity is worth 40 points of the total category score. You can pick 2 medium-weighted activities or 1 high-weighted activity to earn a total of 40 points of the total category score.

To achieve the maximum 40 points for the Improvement Activity score, pick 1 of these combinations:

  • 1 high-weighted activity (any subcategory)
  • 2 medium-weighted activities (any subcategory) Each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score. 

When reporting as a group, your small practice, non-patient facing, rural or HPSA designations must be at the group or virtual group level to qualify for these reduced reporting requirements listed above. Specifically, non-patient facing, rural or HPSA designations must have more than 75% of the NPIs billing under the group’s TIN during the applicable determination period.

Individual reporting for eligible clinicians that are part of groups with 15 or more eligible clinicians, that see patients face-to-face, and are not located in a rural area or Health Professional Shortage Area (HPSA)

Each medium-weighted activity is worth 10 points of the total Improvement Activity performance category score. Each high-weighted activity is worth 20 points of the total category score.

To get the maximum score of 40 points for the Improvement Activity score, pick from any of these combinations:

  • 2 high-weighted activities (any subcategory) 
  • 1 high-weighted activity and 2 medium-weighted activities (any subcategory)
  • 4 medium-weighted activities (any subcategory) 

Improvement Activities can be reported to CMS directly through the Practice Fusion EHR using the Practice Fusion Qualified Clinical Data Registry (QCDR). We will provide more information about participating in the Practice Fusion QCDR for the 2018 performance year in the fall. You may also choose to submit attestation information directly to CMS via the Quality Payment Program website. Reporting for the MIPS 2018 performance year will not begin until January 2019.

Certified Patient-Centered Medical Home Participants

If you’re a MIPS eligible clinician practicing in a certified patient-centered medical home, including Medical Homes Model, or a comparable specialty practice, you’ll earn full credit for the Improvement Activities performance category. Starting in 2018, 50% of practice sites within a multi-practice TIN (or TINs that are part of a virtual group) need to be certified or recognized as a patient-centered medical home to earn full credit for the Improvement Activities in 2018. In 2018 the term “recognized” is the same as the term “certified” as a patient centered medical home or comparable practice. MIPS eligible clinicians or groups are required to attest to being a certified/recognized patient-centered medical home to earn this credit.

Practice Fusion makes reporting for MIPS easy

Practice Fusion’s MIPS Dashboard is an easy-to-manage tool that allows you to track your progress for MIPS. You can use the MIPS Dashboard and its intuitive watch list functionality to monitor your performance on the MIPS measures and activities you may want to report, with no limit to the number of items you can track throughout the year.

Practice Fusion has again been recognized by CMS as a Qualified Clinical Data Registry (QCDR) for the 2018 performance year, which means Practice Fusion EHR customers can efficiently track and report MIPS data to CMS directly through the EHR. More information about participating in the Practice Fusion QCDR will be available in Fall 2018.

More information

  • Access the CMS Fact Sheet for 2018 MIPS Improvement Activities here.
  • Access the CMS Fact Sheet for 2018 Quality Payment Program reporting Year 2 here.
  • CMS also provides further resources for 2018 Quality Payment Program here.

Quality Payment Program

  1. 2018 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  2. What is the MIPS Dashboard watch list and how do I use it?
  3. How does the MIPS Dashboard work?
  4. What is the Promoting Interoperability (formerly Advancing Care Information) performance category in MIPS?
  5. 2018 What is the Quality performance category in MIPS?
  6. 2018 What are Improvement Activities in MIPS?
  7. Which Improvement Activities qualify for the Promoting Interoperability performance category bonus in 2018?
  8. What is the Cost performance category of MIPS and how is it scored in 2018?
  9. How is the MIPS Final Score Calculated in 2018?
  10. What is a MIPS eligible clinician in 2018?
  11. MIPS for Small, Rural and Underserved Practices
  12. 2018 PI Transition Measure: Medication Reconciliation
  13. 2018 PI Transition Measure: Electronic Prescribing (eRx)
  14. 2018 PI Transition Measure: Secure Messaging
  15. 2018 PI Transition Measure: Security Risk Analysis
  16. 2018 PI Transition Measure: Health Information Exchange
  17. 2018 PI Transition Measure: Immunization Registry Reporting
  18. 2018 PI Transition Measure: Specialized Registry Reporting
  19. 2018 PI Transition Measure: Syndromic Surveillance Reporting
  20. 2018 PI Transitional Measure: View, Download, or Transmit (VDT)
  21. 2018 PI Transition Measure: Provide Patient Access
  22. 2018 PI Transition Measure: Patient-Specific Education
  23. What is the Practice Fusion QCDR?
  24. 2017 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  25. How do I report my 2017 MIPS data to CMS using the Practice Fusion QCDR?
  26. What is the Advancing Care Information (ACI) Performance Category for MIPS and how is it scored?
  27. 2017 ACI Transition Measure: Security Risk Analysis
  28. 2017 ACI Transition Measure: Electronic Prescribing (eRx)
  29. 2017 ACI Transition Measure: Provide Patient Access
  30. 2017 ACI Transition Measure: Health Information Exchange
  31. 2017 ACI Transition Measure: View, Download, or Transmit (VDT)
  32. 2017 ACI Transition Measure: Patient-Specific Education
  33. 2017 ACI Transition Measure: Secure Messaging
  34. 2017 ACI Transition Measure: Medication Reconciliation
  35. 2017 ACI Transition Measure: Immunization Registry Reporting
  36. 2017 ACI Bonus Measure: Syndromic Surveillance Reporting
  37. 2017 ACI Bonus Measure: Specialized Registry Reporting
  38. What is the Improvement Activities Performance Category for MIPS?
  39. What are the Quality performance category reporting requirements for MIPS?
  40. What is the difference between the two Advancing Care Information measure sets available in 2017?
  41. What are Alternative Payment Models (APMs) and Advanced APMs?
  42. What is Comprehensive Primary Care Plus (CPC+)?
  43. Which Improvement Activities Qualify for the Advancing Care Information (ACI) Bonus Score in 2017?
  44. How do I contact CMS about the Quality Payment Program?
  45. How do I indicate interest in the Practice Fusion QCDR and get my MIPS estimated scores?
  46. Chronic Care Management FAQs
  47. How do I export a JSON file for 2017 MIPS reporting?
  48. How is the MIPS Final Score Calculated in 2017?

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