While the Quality and Advancing Care Information components account for more significant percentages of a provider’s overall Merit-Based Incentive Payment Systems (MIPS) score (60% and 25%, respectively), one also needs to focus on the work required under the Clinical Practice Improvement Activities component, which comprises 15% of the MIPS score. The Centers for Medicare & Medicaid Services (CMS) recently published an Improvement Activities Fact Sheet detailing the requirements for this MIPS component.
For 2017, there are 92 activities across eight categories from which a provider may select. The eight categories include: (1) achieving health equity, (2) behavioral and mental health, (3) beneficiary engagement, (4) care coordination, (5) emergency response and preparedness, (6) expanded practice access, (7) patient safety and practice assessment, and (8) population management. A provider is not required to select activities from a specific category; instead, a provider should pursue those activities most relevant to his or her practice.
There are a possible 40 points available under the Improvement Activities component. Each activity is assigned a rating of “medium” (78 activities) or “high” (14 activities). Medium-rated activities are worth 10 points, while the high-rated activities are worth 20 points. There is no “partial” credit; a provider will receive the full 10 or 20 points for those activities to which he or she attests to having performed.
The manner in which a provider may earn full credit under this component in 2017 varies:
- Providers who do not meet the criteria specified in items 2 to 5 will need to attest that they completed up to 4 improvement activities (40 points) for a minimum of 90 days during calendar year 2017.
- Groups with fewer than 15 participants and providers practicing in a rural or health professional shortage area will need to attest to completion of up to 2 activities for a minimum of 90 days during 2017. (The point value for each activity is doubled for these providers.)
- Providers practicing in certified patient-centered medical homes, comparable specialty practices, or an alternative payment model (APM) designated as a Medical Home Model (e.g., Comprehensive Primary Care Plus) will automatically earn full credit. For multi-practice groups, if only one practice within the group meets this criterion, the entire group still will receive full credit.
- Providers participating in a Medicare Shared Savings Program Track 1 ACO or in the Oncology Care Model (one-sided only) will automatically earn full credit under the APM scoring standard.
- Providers participating in other APMs will automatically earn half credit and may report additional activities to increase their scores.
If providers elect group reporting (i.e., all providers billing under a TIN report as a single group, as opposed to individual reporting), the group will receive credit for a particular improvement activity even if only one provider in the group completed the activity for the required 90-day period. For 2017, there is no minimum participation requirement for group reporting of an improvement activity, but this is likely to change in later years.
Most providers will report on the Improvement Activities component by submitting an attestation of completion through the CMS Quality Payment Program webpage, through a qualified registry, or through a qualified clinical data registry (QCDR). Providers are required to maintain proper documentation of the completion of each reported improvement activity for at least six years.
Under MIPS, CMS will perform an annual data validation process using randomized audits, and the agency will require approved registries to do the same. If selected for an audit, a provider will be required to produce supporting documentation for its reported activities.
CMS recently published detailed Data Validation Criteria for the Improvement Activities component, specifying the type of documentation required to support completion of each of the 92 activities. (CMS promises to publish similar criteria for the Quality and Advancing Care Information components later this year.) In selecting activities in which to engage and report, a provider should review these documentation requirements, and make sure adequate records are maintained in the event of future audits.
By way of example, the following table summarizes relevant data for one of the improvement activities under each of the eight categories:
CMS will update the list of approved improvement activities each year. In the first quarter of the preceding year, CMS will solicit from the general public recommendations regarding new activities for inclusion. The proposed list for the upcoming year then will be published in the summer, and the final list will become available in late fall.
Finally, under the “Pick Your Pace” program for 2017, a provider may avoid any penalty under MIPS by reporting at least one measure for one of the three components. Thus, by attesting to the completion of only one improvement activity for 90 days during 2017, a provider will not be subject to any MIPS penalty associated with 2019 Medicare Physician Fee Schedule payments.