2021 MIPS Improvement Activities

All Improvement Activities (IA) can be easily attested to with MDinteractive.  This performance category measures participation in activities that improve clinical practice.

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  1. Log into your account
  2. Click on Add/Edit next to the IA category. This will direct you to the IA reporting module.  Note that you might have to enter your NPI/TIN combination or just TIN (if reporting as a group) to be able to see the categories and Add/Edit. 
  3. Enter your minimum 90 day reporting period at the top.
  4. Click “Add” to each activity that you performed for at least 90 consecutive days.  Only "add" activities that you have first reviewed the instructions to ensure you would be able to provide supporting documentation if audited.  Attesting to more than the required abount of activities will not add to your score.

Note:  There are frequency restrictions associated with the following Improvement Activities:  IA_PSPA_4,  IA_PSPA_22, and IA_PSPA_23.  Please review documentation/rules for these activities prior to attestation. 

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Each activity is weighted either medium or high.

To achieve the maximum 15 points for the Improvement Activities score:

A clinician (that works in a group with 15 or fewer providers billing with the same TIN) may select either of these combinations:

  • 1 high-weighted activity OR
  • 2 medium-weighted activities

A clinician with a special status of Non-patient Facing, Health Professional Shortage Area (HPSA) or Rural may select either of these combinations:

  • 1 high-weighted activity OR
  • 2 medium-weighted activities

Clinicians working on larger groups will need to attest to more activities to receive full credit for this category:

  • 2 high-weighted activities OR
  • 1 high-weighted activity and 2 medium-weighted activities OR
  • 4 medium-weighted activities

Important:  Group reporting (reporting on the TIN level) requires that at least 50% of those in the TIN have completed the activity/activities being attested to.

Tips:  Improvement Activities are sorted into the following subcategories which might help you locate activities that are applicable to your practice:

  • Achieving Health Equity (AHE): Engagement of new Medicaid patients and follow-up.
  • Behavioral and Mental Health (BMH):  Activities that look at the co-morbidity of mental health and physical health.  Some cross-over with Quality measures.
  • Beneficiary Engagement (BE):  Engagement of patients through post-visit surveys, tracking reported outcomes, using care plans to manage chronic conditions.
  • Care Coordination (CC):  Coordination of care between clinicians. health information exchange, coordinated planning, etc.
  • Emergency Response & Preparedness (ERP):  Supporting communities by registering to be part of a disaster relief team or participation in supporting humanitarian needs.
  • Expanded Practice Access (EPA):  How accessible you are to your beneficiaries?
  • Patient Safety and Practice Assessment Population Management (PSPA):  Patient safety monitoring programs (i.e. prescriptions drug monitoring, appropriate use of antibiotics, etc.)
  • Population Management (PM):  Population health. Using research, tools, etc.
  • Note: The MDinteractive Suggestions by Specialty page, includes recommendations for activities a clinician or group might be able to attest to.

Here are suggestions regarding the documentation you should have for any attested to Improvement Activity:

  1. List the start date and end date for each activity
  2. Describe the goals, outcomes or metrics for each activity
  3. Describe the process being improved and the benefit of improving the process
  4. List the staff involved for each activity
  5. List the technology used. If possible take screenshots
  6. Describe workflows
  7. Document improvement activities compliance
  8. Describe monitoring systems to gauge your progress towards the goals
  9. Store all documentation in computer files

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