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Taking a closer look at the MIPS Clinical Practice Improvement Activities component

While the Quality and the Advancing Care Information components account for more significant percentages of a provider’s overall MIPS score (60 percent and 25 percent, respectively), one also needs to focus on the work required under the Clinical Practice Improvement Activities component, which comprises 15 percent of the MIPS score. CMS now has 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 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
  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.     

 The manner in which a provider may earn full credit under this component in 2017 varies: 

  1. Providers who do not meet the criteria specified in items 2-5 will need to attest that he or she completed up to four improvement activities (40 points) for a minimum of 90 days during calendar year 2017.
  2. 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 two activities for a minimum of 90 days during 2017. (The point value for each activity is doubled for these providers.)
  3. 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 criteria, the entire group still will receive full credit. 
  4. 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 AMP scoring standard.
  5. 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:

Category

Number of activities (medium and high)

Sample measure

Full description of sample measure

Documentation for sample measure

Achieving Health Equity

Four activities
(3 and 1)

Leveraging a QCDR for use of standard questionnaires (medium)

Leveraging a QCDR for use of standard questionnaires for assessing improvements in health disparities related to functional health.

Participation in QCDR, to use of standard questionnaires for assessing improvements in health disparities, e.g., regular feedback reports from QCDR, demonstrating performance of activities for using standard questionnaires for assessing improvements in health disparities related to functional health status.

Behavioral and Mental Health

Eight activities (6 and 2) 

Implementation of co-location of  PCP and MH services (high)

 

Integration facilitation, and promotion of the co-location of mental health services in primary and/or non-primary clinical care settings.

Documentation of integration and promotion of the co-location of mental health and substance use disorder services in primary and/or non-primary clinical care settings, e.g., list of NPIs that participate as behavioral health specialists, mental health clinicians or primary care clinicians in co-located setting or patient claims showing mental health and substance use disorder services collocated in primary and/or non-primary clinical care settings.

Beneficiary Engagement

23 activities (22 and 1)

Implementation of condition-
specific chronic disease self-
management support programs (medium)

Provide condition-specific chronic disease self-management support programs or coaching, or link patients to those programs in the community.

 

(1) Chronic Disease Self-Management Support Program - Documentation from medical record or EHR showing condition specific chronic disease self-management support program or coaching; or (2) Community Chronic Disease Self-Management Support Program - Documentation of referral/link of patients to condition-specific chronic disease self-management support.

Care Coordination

14 activities (13 and 1)

Care transition standard operational improvement (medium)

 

(1) Establish standard operations to manage transitions of care, e.g., establish formalized lines of communication with local settings in which empaneled patients receive care; and/or (2) partner with community or hospital-based transitional care services.

(1) Documentation of formal lines of communication to manage transitions of care with local settings (e.g. community or hospital-based transitional care services) in which empaneled patients receive care to ensure documented flow of information and seamless transitions; or 2) Documentation showing partnership with community or hospital-based transitional care services.

Emergency Response and Preparedness

Two activities (1 and 1)

Participation in Disaster Medical Assistance Team or Community Emergency Responder Team (medium)

Registration alone is insufficient. Clinicians and groups must be registered for at least six months as a volunteer for disaster or emergency response.

 

Documentation of participation in Disaster Medical Assistance or Community Emergency Responder Teams for at least six months including registration and active participation, e.g., attendance at training, on-site participation.

Expanded Practice Access

Four activities (3 and 1) 

Use of telehealth services to expand practice access (medium)

 

Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or tele-audiology pilots that assess ability to still deliver quality care to patients.

(1) Use of Telehealth Services - Documented use of telehealth services through: a) claims adjudication (may use G codes to validate); b) certified EHR or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient; and (2) Analysis of Assessing Ability to Deliver Quality of Care - Participation in or performance of quality improvement analysis showing delivery of quality care to patients through the telehealth medium (e.g. Excel spreadsheet, Word document).

Patient Safety and Practice Assessment

21 activities (19 and 2)

Implementation of antibiotic stewardship program (medium)

Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics.

 

Documentation of implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics and identifies improvement actions.

Population Management

16 activities (11 and 5)

Implementation of episodic care management practice improvement (medium)

 

Provide episodic care management, including (1) follow-up to hospitalizations, ED visits and stays in other institutional settings, (including symptom and disease management, and medication reconciliation and management); and/or (2) managing care intensively through new diagnoses, injuries, and exacerbations of illness.

(1)  Follow-Up on Hospitalizations, ED or Other Visits and Medication Management – Routine and timely follow-up to hospitalizations, ED, or other institutional visits, and medication reconciliation and management (e.g. documented in medical record); or (2) New diagnoses, Injuries, and Exacerbations - Care management through new diagnoses, injuries and exacerbations of illness (medical record).

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 the 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 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.