The Improvement Activities Performance Category is a new concept introduced by MIPS reporting and rewards eligible clinicians for participating in activities related to their patient population. Clinicians and groups can choose to participate in activities most relevant to both their practice and patient population. The Improvement Activities Performance Category is worth 15% of the MIPS Composite Performance Score in 2017.

Determine MIPS Eligibility and Level of Reporting (TIN or NPI)

The first step to MIPS reporting is determining if you need to report, and if you will be reporting on a group (TIN) or individual (NPI) level. Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists are all considered eligible clinicians in 2017. MIPS reporting will be required for eligible clinicians who are not participating in an Advanced Alternative Payment Model, see at least 100 Medicare Part B beneficiaries, and at have at least $30,000 in Medicare Part B allowed charges.

Whether you report as a group or as an individual, you must do so for every performance category of MIPS. Groups will be determined on the TIN level, and may contain all clinicians that would otherwise be considered ineligible. 

Determine Required Points for Success

Forty points is the standard number of required points to receive full credit in the Improvement Activities Performance Category. This will make you eligible for both penalty avoidance and an incentive payment.

20 points

Practices with 15 or fewer professionals, rural practices, Health Professional Shortage Areas (HPSAs), and non-patient facing clinicians can receive full credit for the Improvement Activities Performance Category at 20 points. These professionals will be eligible for both penalty avoidance and an incentive payment at 20 points, but all other eligible clinicians or groups would only receive partial credit.

Partial QPs that are participating in an Alternative Payment Model (APM) can report only additional 20 points in this category as well, since participating in an APM results in an automatic 20 out of the 40 required points.

10 points

Eligible clinicians or groups simply seeking to avoid the penalty need only report 10 points worth of Improvement Activities. This will result in penalty avoidance, but will not result in an incentive unless combined with reporting in other Performance Categories.

0 points

Certified Patient Centered Medical Homes will receive full credit for the Improvement Activities Performance Category automatically, so no further reporting is necessary.

Select Improvement Activities

Activity Weighting

There are 92 available improvement activities to choose from. High-weight activities are worth 20 points, and medium weight activities are worth 10 points. Choose any combination of activities to receive the required number of points!

Crossovers with other Performance Categories

Certain activities count for up to 10 bonus points in the Advancing Care Information Performance Category. Additionally, four measures in the Behavioral and Mental Health subcategory of Improvement Activities overlap with measures from the Quality Performance Category. We can expect to see further overlaps in categories in the future as one of the objectives of MIPS is to have the Performance Categories have clearer links to each other. Participating in CAHPS for MIPS in the Quality Performance Category is also counted as a high-weight activity.

Review Data & Submit!

Improvement activities can be submitted via QCDR, Registry, EHR, or by attestation. Eligible practices reporting as a group (TIN level) can also report through the CMS web interface.