How to Succeed in the MIPS Improvement Activities Category

The Improvement Activity Performance category is one of the four categories within MIPS that assesses your participation in clinical activities that support the improvement of clinical practice, care delivery, and outcomes. There are over 100 activities to choose from and below you will find the key resources to assist you in reporting and audit preparation.

If you have been reporting Traditional MIPS over the past couple of years, you most likely have one or two Improvement Activities that you typically rely on for your practice to report. Whether it has been a few years since you reported (utilized the COVID-19 Hardship) or you are an MIPS pro, it is always important to review the Improvement Activity Category measures each year to guarantee that the measure is still available or to review any significant changes to the measure.  It is also crucial that you have the necessary documentation so that you know exactly what is required for each activity for audit purposes.

What’s New With Improvement Activities in 2024?

Added 5 Improvement Activities

1. Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services (IA_PM_22)
2. Practice-Wide Quality Improvement in MIPS Value Pathways (IA_MVP)
3. Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines (IA_PM_23)
4. Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women (IA_BMH_14)
5. Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults (IA_BMH_15)

Removed 3 Improvement Activities

1. Implementation of co-location PCP and MH services (IA_BMH_6)
2. Obtain or Renew an Approved Waiver for Provision of Buprenorphine as Medication Assisted Treatment [MAT] for Opioid Use Disorder (IA_BMH_13)
3. Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging (IA_PSPA_29)

Modified 1 Improvement Activity

1. Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools—and standardized treatment protocols to manage workflow on the care team to meet patient needs (IA_PSPA_16)

Reporting Requirements

Like the 2023 MIPS Performance Year, Improvement Activities are still required to have a continuous 90-day reporting period. This can be any consecutive 90-days and does not need to align with a quarter.

Most clinicians must implement and submit 2 to 4 improvement activities to receive the maximum score of 40 points in this performance category. Each individual improvement activity is assigned a weight of either medium or high. Medium-weighted activities receive 10 points and high-weighted activities receive 20 points. To receive full credit for the performance category, eligible clinicians and groups must receive a score of 40 points.

Things to Remember

Now, if you are part of a small practice (less than 15 Clinicians), rural practice, practice located in geographic health professional shortage areas (HPSAs), or are a non-patient facing MIPS eligible clinician, the weights are doubled. Medium-weighted activities count for 20 points and high-weighted activities count for 40 points. Essentially, you would only have to report half of what is normally required to earn full credit.

If you are reporting as a group, CMS requires 50% of the group’s National Provider Identifier (NPI) clinicians to perform the same improvement activity during any continuous 90-day period within the same performance year.

You can also receive credit in this performance category from your participation in certain improvement activities or payment models:

• Participate in a certified or recognized patient-centered medical home or comparable specialty society would earn you full credit.
• Participate in an APM would earn at least 20 points out of 40 possible.

IA and Your Final Score

The Improvement Activity category weight depends on how you are reporting and what categories you are going to report on. The traditional weight for the IA category is 15% or 15 points toward your final score. However, if you are a small practice, exempt from the Promoting Interoperability category, IA would be weighted at 30%.

Select your Improvement Activities

At DAS Health, we know selecting activities can seem overwhelming with the amount of options available, so we rounded up our most used:

We always recommend clients select an activity that aligns with a clinical quality measure or promoting interoperability measure they are reporting on if possible! Here are some ideas:

CMS 50: Closing the Referral Loop: Receipt of Specialist Report

IA_CC_1 Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop

CMS 139: Falls: Screening for Future Fall Risk

IA_PSPA_21 Implementation of fall screening and assessment programs

CMS 68 Documentation of Current Medications

A_PM_16 Implementation of medication management practice improvements

CMS 2: Depression Screening and Follow-up

• IA_BMH_4 Depression screening
• IA_AHE_3 Promote use of Patient-Reported Outcome Tools

Provide Patients Electronic Access to Their Health Information

Activity IA_BE_4: Engagement of patients through implementation of improvements in patient portal

Other Improvement Activities we recommend, include:

• IA_EPA_1 Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record
• IA CC 13: Practice improvements to align with OpenNotes principles
• IA_PSPA_8 Use of Patient Safety Tools
• IA_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements

Supporting Documentation

After you have chosen the Improvement Activities that make the most sense for your practice, we recommend you review the 2024 Data Validation Criteria. Here you will find all the necessary information to make sure you are compiling the documentation that CMS suggests in case of an audit. You need to keep this documentation for up to six years.

The 2024 MIPS Data Validation Criteria document which will help you understand improvement activity documentation requirements:

• Contains examples of ways to demonstrate completion of each improvement activity and clarifies the flexibilities clinicians have in implementing the activities.
• Articulates the objective of each activity.
• Includes MIPS Data Validation Criteria for the Promoting Interoperability performance category.

Common examples of documentation may include, but are not limited to:

• Screenshot or digital capture of relevant information supporting the attestation.
• Improvement plans and/or outlines supporting the interventional strategies/processes implemented to meet the intent of the improvement activity.
• Electronic Health Record Report: Retain a copy of documentation relevant to the chosen improvement activity as evidence of attestation.

We should point out, you can attest to more than 40 points worth of activities, but you will not be able to earn more than 40 points. So, if you do attest to more activities, you will be responsible for maintaining all the documentation for every measure you attest to. 

We Are Here to Help!

At DAS Health, we understand the complexities of the program and it is our full-time job to be experts in the program! So let us help you earn the maximum incentive possible and be successful under MIPS!

Written by: Bridget Peterson