Posted on July 8, 2021
The MIPS Improvement Activities (IA) performance category measures a clinician or group’s engagement in clinical activities that improve clinical practice, care delivery, and outcomes. It is one of four categories under the MIPS program. This year clinicians will need to attest to Improvement Activities, in addition to reporting the MIPS Quality and Promoting Interoperability categories, to ensure they reach the new minimum threshold of 60 points to avoid a MIPS penalty. This article provides an overview of the Improvement Activities category, explains how to maximize MIPS points, and offers tips on selecting activities most relevant to a clinician’s practice.
MIPS Improvement Activities (IA) - The Basics
The MIPS Improvement Activities category is designed to reward clinicians for participating in clinical practice improvement activities. This category is worth 15% of the final MIPS score (note the percentage can change based on Alternative Payment Model (APM) Entity participation) and involves a simple attestation process. Similar to the Promoting Interoperability (PI) category, the Improvement Activities category has a continuous 90-day performance period unless otherwise stated in the activity description.
What's New in 2021?
There were very few changes made to the Improvement Activities category in 2021:
- CMS is continuing the High-weighted IA_EPR_3 COVID-19 Clinical Data Reporting with or without Clinical Trial activity for the 2021 performance year.
- CMS modified 2 existing Improvement Activities:
- IA_BE_4 Engagement of Patient through Implementation of Improvements in Patient Portal. The modification adds language to include caregivers as additional potential users of the patient portal given the important role caregivers can play in bidirectional information exchange regarding the clinical care of the patient. Language was also added to clarify that the portal’s primary use should be clinical and not administrative.
- IA_AHE_7 Comprehensive Eye Exams. The modification adds language that expands the types of services that eligible clinicians can promote to underserved and/or high-risk populations to receive credit for this activity.
- CMS removed 1 activity that can no longer be reported:
- IA_CC_5 - CMS Partner in Patients Hospital Engagement Network
List of 2021 Improvement Activities
There are 105 Improvement Activities to choose from in 2021. All of the activities are divided into eight subcategories, and each activity is designated as “High-weighted” or “Medium-weighted”. Our website includes a filter to search by subcategory, or High or Medium-weighted activities.
|Expanded Practice Access||Population Management|
|Care Coordination||Beneficiary Engagement|
|Patient Safety and Practice Assessment||Achieving Health Equity|
|Integrating Behavioral and Mental Health||Emergency Preparedness and Response|
*Clinicians don’t have to select activities in each subcategory nor select activities from a certain number of subcategories.
Reporting and Documentation Requirements
Clinicians reporting this category simply attest to performing an activity or activities for a 90-day reporting period during the performance year. Most activities require a continuous 90-day reporting period, so the last day to start a new activity is October 3, 2021. If a particular activity has a shorter or longer reporting period (e.g., IA_CC_10 Care transition documentation practice improvements has a 30-day reporting period) it will be specified in the Improvement Activity description. Clinicians can generally attest to the same activity for multiple reporting years unless otherwise specified in the activity documentation.
Important: When reporting as a group at least 50% of the clinicians (in the group or virtual group) must perform the same activity during any continuous 90-day period, or as specified in the activity description, within the same performance year. The clinicians do not have to perform the activity during the same 90-day period.
Improvement Activity Criteria
For each activity, CMS has included an activity description and suggested documentation. This information should be carefully reviewed before completing the attestation to ensure the clinical activity being measured has been performed. Clinicians should have documentation demonstrating they performed the clinical activity as specified in the CMS description. Additionally, it is important to note that Improvement Activities are not the same as Quality measures. Quality measures assess if a particular outcome occurred at a patient encounter. Improvement Activities indicate that the clinician has implemented clinical activities that improve clinical practice, care delivery, and outcomes overall.
Some examples of activities that might be confused with a Quality measure or are commonly misinterpreted:
- IA_BMH_2: Tobacco use. This activity involves regular engagement in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions, for patients with co-occurring conditions of behavioral or mental health and at-risk factors for tobacco dependence. The clinical activity differs from Quality measure #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention which is reported for eligible patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user.
- IA_PM_21: Advance Care Planning. This activity involves the implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning, motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning. This activity differs from Quality measure #047: Advance Care Plan which is reported on eligible patients aged 65 years and older who have an advance care plan or surrogate decision-maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision-maker or provide an advance care plan.
- IA_AHE_6: Provide Education Opportunities for New Clinicians. This activity applies to clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas. Clinicians must show evidence of clinical rotation assignments in community practices in small, underserved, or rural areas to attest to this activity.
Improvement Activity Documentation
Clinicians are not required to submit supporting documentation at the time of attestation. However, CMS requires that documentation be retained to confirm the completion of the activity for six years following the performance period in the event of an audit. CMS lists suggested documentation for each activity, but other general suggestions include:
- List the start date and end date for each activity.
- Describe the goals, outcomes, or metrics for each activity.
- Describe the process being improved and the benefit of improving the process.
- List the staff involved in each activity.
- List the technology used (if possible take screenshots).
- Describe workflows.
- Document improvement activities compliance.
- Describe monitoring systems to gauge your progress towards the goals.
- Store all documentation in computer files.
The number of activities required to maximize MIPS points for this category (15 MIPS points) will depend on the size of the practice and any special status designation*. Attesting to more than the required number of activities will not increase a clinician or group’s MIPS score.
*Special status: Small practice, Rural, Health Professional Shortage Area (HPSA), Non-Patient Facing
TIPS on Selecting Your Improvement Activities
When selecting Improvement Activities, it is important to identify activities that are relevant to your practice and patient population.
✔Review suggestions for your specialty to see if any apply to your practice or if you are already performing any activities as part of your normal workflow.
✔Review the entire list of activities if none of the specialty recommendations apply to your practice.
✔Narrow the list of activities by subcategory, High or Medium-weight, to make the list more manageable.
✔Look for activities you have already implemented in your practice. In some cases, you may be performing an activity but calling it by a different name.
✔Carefully review the activity description and suggested documentation to ensure you understand the CMS expectations and can provide documentation as proof that you completed the activity.
Some commonly reported Improvement Activities:
Improvement Activities that involve:
- Patient reminders of missed or overdue services:
- Prescription Monitoring Program / Opioid prescriptions:
- Placing and tracking orders and communicating test results:
- Identifying and caring for patients following a hospitalization or an emergency room visit:
- Review of targeted population needs:
- Dissemination of patient experience and satisfaction surveys:
- Participation in domestic and international volunteer activities:
- Pre-visit planning:
- Individualized care plans and medication management practices:
- Preventive health screenings and behavioral health services:
- Staff education and assessment:
- Telehealth services and chronic disease management support:
- Participation in community and national quality improvement programs:
- Case management, care transition and care coordination activities:
- Support from ancillary staff:
- Adoption of evidence-based performance improvement processes:
- EHR functionality:
- Practice workflow and EHR improvements to support care management and patient education:
Completing your Improvement Activities Attestation
The MIPS Improvement Activities category is worth up to 15 MIPS points and requires a simple attestation process. There are over 100 activities to choose from, so you should select activities that are relevant to your practice and support the needs of your patients. MDinteractive has posted Improvement Activities by specialty in addition to the full list on our website. We have also developed simple instructions explaining how to complete the attestation process in your MDinteractive account. MIPS eligible clinicians must reach 60 MIPS points in 2021, so attesting to Improvement Activities, in addition to reporting the MIPS Quality and Promoting Interoperability categories, can help you meet this minimum threshold to avoid a MIPS penalty.
MIPS Reporting MACRA Improvement Activities Attesting to Improvement Activities