MIPS Improvement Activities Fact Sheet
(TOTAL MAXIMUM SCORE 40)
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:
TWO high-weighted activities
ONE high-weighted activity and 2 medium-weighted activities
FOUR medium-weighted activities
“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”
Groups with 15 or fewer clinicians, non-patient facing
clinicians and/or clinicians located in a rural area or
Each activity is weighted either medium or high. To achieve the maximum 40 points for the Improvement Activity score, you may select either of these combinations:
ONE high-weighted activity
TWO medium-weighted activities
Each medium-weighted activity is worth 20 points and a high-weighted activity is worth 40 points.
You may select two medium-weighted activities or one high-weighted activity to receive a total of 40 points of the total category score.
“Each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and each high-weighted activity is worth 40 points of the total category score”
The Improvement Activity performance category counts for 15% of your MIPS final score
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).
Eligible clinicians are encouraged to retain documentation for 6 years as required by the CMS document retention policy.
You may report activities using a qualified registry, via certified EHR Technology), qualified clinical data
registry (QCDR), the CMS Web Interface (for groups of 25 or more), or via attestation. These
intermediaries will need to certify that you performed the activities as indicated
For more information click on this link for MIPS FACT SHEET
For choosing MIPS IMPROVEMENT ACTIVITIES CLICK ON LINK BELOW:
MIPS improvement activities detial
Review and select activities that best fit your practice.
Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.
Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.
Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
There are 93 categories to choose from. Out of 93, 13 or high weighted. 80 re medium weighted. High weighted are marked in bold and orange color to identify them easily.
Additional improvements in access as a result of QIN/QIO TA
Administration of the AHRQ Survey of Patient Safety Culture
Annual registration in the Prescription Drug Monitoring Program
Anticoagulant management improvements
Care coordination agreements that promote improvements in patient tracking across settings
Care transition documentation practice improvements
Care transition standard operational improvements
Chronic care and preventative care management for empanelled patients
CMS partner in Patients Hospital Improvement Innovation Networks
Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
Collection and use of patient experience and satisfaction data on access
Completion of the AMA STEPS Forward program
Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
Consultation of the Prescription Drug Monitoring program
Electronic Health Record Enhancements for BH data capture
Engage patients and families to guide improvement in the system of care.
Engagement of community for health status improvement
Engagement of new Medicaid patients and follow-up
Engagement of patients through implementation of improvements in patient portal
Engagement of patients, family and caregivers in developing a plan of care
Engagement with QIN-QIO to implement self-management training programs
Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
Evidenced-based techniques to promote self-management into usual care
Glycemic management services
Implementation of additional activity as a result of TA for improving care coordination
Implementation of analytic capabilities to manage total cost of care for practice population
Implementation of antibiotic stewardship program
Implementation of co-location PCP and MH services
Implementation of condition-specific chronic disease self-management support programs
Implementation of documentation improvements for practice/process improvements
Implementation of episodic care management practice improvements
Implementation of fall screening and assessment programs
Implementation of formal quality improvement methods, practice changes or other practice improvement processes
Implementation of improvements that contribute to more timely communication of test results
Implementation of integrated PCBH model
Implementation of medication management practice improvements
Implementation of methodologies for improvements in longitudinal care management for high risk patients
Implementation of practices/processes for developing regular individual care plans
Implementation of use of specialist reports back to referring clinician or group to close referral loop
Improved practices that disseminate appropriate self-management materials
Improved practices that engage patients pre-visit
Integration of patient coaching practices between visits
Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
Leveraging a QCDR for use of standard questionnaires
Leveraging a QCDR to promote use of patient-reported outcome tools
Leveraging a QCDR to standardize processes for screening
MDD prevention and treatment interventions
Measurement and improvement at the practice and panel level
Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.
Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
Participation in a QCDR, that promotes implementation of patient self-action plans.
Participation in a QCDR, that promotes use of patient engagement tools.
Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.
Participation in an AHRQ-listed patient safety organization.
Participation in Bridges to Excellence or other similar program
Participation in CAHPS or other supplemental questionnaire
Participation in CMMI models such as Million Hearts Campaign
Participation in Joint Commission Evaluation Initiative
Participation in MOC Part IV
Participation in population health research
Participation in private payer CPIA
Participation in systematic anticoagulation program
Participation on Disaster Medical Assistance Team, registered for 6 months.
Patient Centered Medical Home Attestation
Practice improvements for bilateral exchange of patient information
Practice improvements that engage community resources to support patient health goals
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record
Provide peer-led support for self-management.
Regular review practices in place on targeted patient population needs
Regular training in care coordination
Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
RHC, IHS or FQHC quality improvement activities
Unhealthy alcohol use
Use evidence-based decision aids to support shared decision-making.
Use group visits for common chronic conditions (e.g., diabetes).
Use of certified EHR to capture patient reported outcomes
Use of decision support and standardized treatment protocols
Use of patient safety tools
Use of QCDR data for ongoing practice assessment and improvements
Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
Use of QCDR for feedback reports that incorporate population health
Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.
Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
Use of QCDR to support clinical decision making
Use of telehealth services that expand practice access
Use of tools to assist patient self-management
Use of toolsets or other resources to close healthcare disparities across communities