[PART 4] Understanding MIPS 2018: Improvement Activities

By Denise Scott, M.M. RN-BC, CMHP. Posted Mar 09, 2018 in Quality Reporting, MACRA/MIPS Program, Academy

We are finishing up our four-part MIPS series in which we dig deep into each reporting category of MIPS. We offer tips to succeed and explore ways to identify the nuances of each category.

In this final part of our series, we explore the Improvement Activities category of MIPS, which is the only category that did not replace a former CMS program. The other MIPS categories all replaced former CMS reporting programs. 

Of all the MIPS category requirements for 2018 submission, the Improvement Activities category might be the simplest to understand.

The measures are not narrowly defined, so you have a bit more room for interpretation. This flexibility allows clinicians the ability to make the measure work in a way that has meaning for them, their staff or their patients.

If you haven’t had a chance to read the other deep dive blogs, check out the links below.

Also See: [PART 1] Understanding MIPS 2018
Also See: [PART 2] Understanding MIPS 2018: Cost and Quality
Also See: [PART 3] Understanding MIPS 2018: Advancing Care Information

MIPS Improvement Activities (IA) Category 2018

This category of MIPS is focused on rewarding innovation with improvement activity measures that center around things such as care coordination, engaging beneficiaries, patient safety, expanding patient access and population management. Just as it was in 2017, the Improvement Activities category is worth 15% of your total MIPS score for 2018.

Improvement Activities Category Requirements 2018

There are 112 Improvement Activity measures for you to choose from this year. These activities revolve around providing a patient-centered approach to improve your clinical practice or your care delivery.

You must report up to four measures to equal a score of 40 points to earn full credit for this category. You also must report each measure with data documenting that the activity was done for a minimum of 90 consecutive days. Keep in mind that the measures you report do not have to be from the same 90-day period. In fact, since only 90 days is required, you should sort out which 90-day time frame gives you the best performance results for each measure you submit.

Improvement Activity measures come in two categories, high-weight measures and medium-weight measures. High-weight measures are worth 20 points each. Medium-weight measures are worth 10 points each. To achieve maximum performance, you must report a combination of measures that equals 40 points. 

If you choose two high-weight measures, that would fulfill your 40-point requirement; if you choose all medium-weight measures, you would need to report four measures. And obviously, the other option is one high-weight and two medium-weight measures.

Small Practices and the Improvement Activities Category

CMS has made accommodations for small practices. Anyone with less than 15 Eligible Clinicians or Rural Health and Health Professional Shortage Areas have their point worth doubled. A high-weight measure is worth 40 points and medium-weight measures are worth 20 points. 

Essentially, any practice or eligible clincian who meet one of those qualifying categories would only need to do one high-weight activity or two medium weight activities to receive full credit for this category.

Selecting your Improvement Activity measures

When selecting your measures, there are a couple of things to keep in mind. My first recommendation is to start as early as you can in 2018 so you can actually improve your score over the reporting period.

When you select your Improvement Activity measure, it’s best to choose a measure that you’re already working on or measures that are pertinent to your group. 


Bonus Eligible Improvement Activity Measures

This might be the only confusing part about the Improvement Activities category of MIPS. There are certain Improvement Activities that actually award you bonus points in the Advancing Care Information category. These measures are identified as Improvement Activities that CEHRT could be used for the activity. When choosing your IA measures, consider which of these measures will afford you that 10-point bonus in the Advancing Care Information category. The Quality Payment Program website has a PDF that lists all of the Improvement Activity measures that are eligible for the Advancing Care Information bonus points in 2017. Unfortunately, they have not released the 2018 measure list yet, but the 2017 list would be a good starting point.


Reporting Improvement Activities Measures

Here are some additional cautions for this category.

Report One Measure Once

Each of the 112 Improvement Activity measures have an Activity ID. When we as a vendor report which measures you are submitting to MIPS, we are going to use that Activity ID. Even though you might be able to design multiple improvement projects around this one Improvement Activity, CMS only permits you to submit that Activity ID once. That’s not to say you can’t have multiple improvement activities going on for this measure, you just can’t get all of your category points by using one measure.

Report For 90 Days

You must have evidence of your work on these measures for a minimum of 90 consecutive days. However, they don’t need to be the same 90 consecutive days for each measure. You can work on different measures at different times of the year and for the length of time you choose, as long as it is more than 90 days.

Retain Evidence of Improvement

Keep evidence as you work on improving those measures for 90 days. Take a measurement at the beginning and at the end of your 90 days and compare your results so you have proof that you did or did not make any improvement.

Patient Center Medical Homes

The rules for Patient Center Medical Homes (PCMH) have changed slightly for 2018. Last year, if you were a recognized Patient Center Medical Home, you received all of the points for this category without submitting any measures. This year is the same, but you only get the full credit if more than 50% of the practices in your TIN are recognized as Patient Center Medical Homes. CMS will look at the physical location as indicated in PECOS to make this determination. It’s your job to figure out if more than 50% of the practices in your TIN are recognized as PCMHs.

If you are unsure of your status, the Quality Payment Program website has a phone number and email system at the bottom of their website, where you can ask the MIPS staff your question.

Tips for the Improvement Activities Category

In summary, here are my top tips to succeed in the Improvement Activities category of MIPS. 

  1. Aim for 40 points, which will give you the full category credit of 15% of your total MIPS score.
  2. Start early to use this category to improve.
  3. Select at least one Improvement Activity measure that is designated for Advancing Care Information bonus points.
  4. Choose measures that you are already working on, but you haven’t formalized the process. Or choose measures that are pertinent to your group.
  5. Document your starting point.
  6. Keep evidence of your work on the measure.
  7. Measures do not need to be from the same 90-day consecutive time frame.
  8. Confirm that over 50% of your practices within your TIN are also designated as PCMHs.

To get started in this category, it’s best to determine your 2018 reporting plans. Which measures are you going to report and what time of the year? Decide if you will be reporting as an individual or a group. Determine which reporting method you will use, attestation, EHR, etc. Find a reporting vendor (like Medisolv) that will help you submit all of your MIPS category requirements from one software system. Then have your organization agree to the plan, document and retain proof for at least six years in case of CMS audits.

Finally, choose a MIPS vendor carefully and understand how they will support you in the calculation of your possible MIPS points in the Improvement Activities category, as well as help you to meet all of the MIPS program requirements.

If you would like to learn more about the Medisolv MIPS solution, please contact us today.



What’s in store for MIPS year three?

In this free educational webinar, we discuss who is eligible for the MIPS program in 2019 and what’s required for successful completion of the program. We also outline strategies that will help your providers gear up for their best reporting year yet.

Here’s what's covered in this webinar:

  1. Changes made in the 2019 final rule for the Quality Payment Program
  2. Reporting requirements for MIPS
  3. How the final score is calculated
  4. Best practices for preparing your clinicians for a successful quality reporting year

Speaker info:
Denise Scott
Director of Ambulatory Service 
Medisolv, Inc

Download Webinar Now

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Denise Scott, M.M. RN-BC, CMHP

Denise Scott, M.M. RN-BC, CMHP

Denise Scott, Director of Ambulatory Services, brings over 30 years in healthcare and over 15 years in HIT implementation, optimization, quality measurement and improvement in the ambulatory physician environment to Medisolv. Prior to joining Medisolv, Denise was a Director of Quality, Informatics and Clinical Integration for two large medical groups in Massachusetts and the former Manager, HIT Services at Masspro where she led a variety of HIT related projects. Denise is a subject matter expert on workflow redesign and Meaningful Use, and is board certified in Nursing Informatics.

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