MIPS: Breaking Down the Improvement Activities Category

Posted on  June 29, 2017



The Improvement Activities category of MIPS is the category that counts the least for the performance year 2017. It contributes only 15% to your total composite performance score. It’s the new category that does not replace any previous quality program but rather is meant to enhance the Quality Payment Program overall with regards to turning the focus towards quality versus quantity.


The first step in participating in the Improvement Activities category is to understand how many activities you must participate in. For most participants in MIPS, you will complete up to four activities for a minimum of 90 days. However, there are several factors that will affect the number of activities you must choose. Those are:

1. Groups with fewer than 15 participants or practices located in a rural or health professional shortage area must attest to have completed up to two (2) activities for a minimum of 90 days.

2. Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model will automatically earn full credit without having to choose any improvement activities.

3. Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM will automatically be scored based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.

4. Participants in any other APM will automatically earn half credit and may report additional activities to increase their score.

So based on the above factors, your next step for success in this category is finding the activities that are most relevant and suitable for your practice. Currently, there are 92 improvement activities to choose from. CMS has provided a tool similar to the quality measures search engine to help you narrow down the list. The first filter is for the subcategory name which consists of eight different subcategories such as Behavioral and Mental health, Care Coordination and Population Management.

Another filter they provide is for the activity weighting. If the Activity is medium weight, it is worth 10 points. If the activity has a high weighting it is worth 20 points. During the initial performance year, this does not matter quite as much as in future years. Make sure you try to do a heavy-weighted activity in order to earn more points.

Now let’s take a look at some of the most popular activities that will more than likely have the most participation across the board.

Implementation of use of specialist reports back to referring clinician or group to close referral loop.
This is one activity that every type of specialist could participate in rather easily. The sub-category name is Care Coordination. If you’re already using a certified EHR then you are in luck because most of the systems available will have an automated way that will send summary reports to the referring provider with just a couple of mouse clicks. Because of this, there’s minimal cost and time investment required. In fact, you might already be doing this and simply need to document it for the purposes of reporting next year. Of course, this activity has a medium weight due to simplicity which makes it worth only 10 points.

Population Empanelment.
Once again, this might be an activity that is already occurring in your practice and just needs to be documented for reporting. Empanelment, for this purpose, means that you are assigning responsibility for a patient to a MIPS eligible clinician. To ensure that 100% of our patients are empaneled you could have your scheduling staff simply confirm the assignment when they are scheduling appointments. Because some patients don’t come in often, you will probably want to identify the patients that have sought care within the last 24 to 36 months and then make sure they are empaneled. Once again, this is a medium-weighted activity that is worth 10 points.

Use of telehealth services that expand practice access.
This is an actual improvement activity that could also improve your bottom line. The interesting part is that no matter how large your group is, only one of the providers must be offering telehealth services in order for it to count. Because telehealth is becoming so popular, you will not only meet MIPS requirements, but it will also help you stay competitive in the marketplace. The subcategory name is Expanded Practice Access and it is a medium-weighted activity worth 10 points.


Now let’s review scoring so you can understand how it works. As long as you are meeting the activity requirements and have documentation to prove it, you will earn the full amount of points for your activity. If you’re a small practice required to do 2 activities in this first year, and you chose medium activities, your score would be 20 points. If you’re a large practice that chose 4 activities, perhaps they were 2 heavy and 2 medium, your score would be 60. Either way, based on the size of your practice, we’re going to assume that you did meet the criteria of the activity and can prove it with documentation. In that case, you’ll attest yes. Whether your score is 40 or 60 or even 20, here is the math equation you will use:

Score x 15% =? or using the example below: 40 x 15% = 6

If your score was 40 then you multiply it by 15% and that is what will be added to your total composite performance score for this category. Because this category has the least weight, make sure you focus more on the quality and advancing care categories in the first performance year.

Take the time to come back for our next article where we’ll be breaking down the Advancing Care Information category which is replacing Meaningful Use.

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Comments 22

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