2018 MIPS

Improvement Activities Performance Category Frequently Asked Questions (FAQs) 

What is the Improvement Activities Performance Category?

In the new performance category created by CMS for MIPS to support broad aims within healthcare including care coordination, beneficiary engagement, population management, and health equity, clinicians are rewarded for activities that improve clinical practice, such as shared decision making and increasing access. According to CMS, “improvement activities are those that improve clinical practice or care delivery and that, when effectively executed, are likely to result in improved outcomes. The activities were recommended by clinicians, patients, and other stakeholders interested in advancing quality improvement and innovations in healthcare”. This, along with other more detailed information about 2018 MIPS, can be found within the CMS 2018 MIPS Executive Summary.

For the Improvement Activities Performance Category, Eligible Clinicians (ECs) attest that they have participated in activities of import such as, but not limited to, care coordination, beneficiary engagement, and patient safety and practice assessment. ECs and groups eligible to participate in MIPS can select from 113 IA measures from a list of activities in these areas developed by CMS through stakeholder engagement.

While each IA is worth a set number of points, to achieve the maximum number of IA points, ECs need to identify a certain number IA measures to achieve a total of forty points to fully satisfy reporting requirements in the improvement activity category.

Am I required to participate and report for the MIPS Improvement Activities Category?

While not required, for all CRNAs who are subject to MIPS reporting in 2018, reporting measures within the IA Category is highly recommended in order to reach a minimum MIPS Composite Score of 15 points. Meeting the final MIPS score threshold of 15 points will avoid a negative payment adjustment.

There are reduced requirements within the Improvement Activities Category for ECs with “special status” under MIPS. CRNAs can check their 2017 MIPS participation status with their National Provider Identification Number (NPI) by using the CMS MIPS Participation Status Tool. At this time, the 2018 Participation Status Tool has not yet been posted. CRNAs should check their status on the CMS website using the MIPS Participation Status Lookup Tool.

In particular, many CRNAs will qualify for the non-patient facing special status exception under the IA category because, as outlined in the CMS QPP Year 2 Fact Sheet, ECs in “small practices, practices in rural areas, geographic health professional shortage areas (HPSAs); and non-patient facing MIPS eligible clinicians need 2 activities (2 medium or 1 high-weighted activity) to earn the full score”.
Special Status Definitions Table

How can I achieve maximum potential points in the Improvement Activities Performance Category?

For participation in the Improvement Activities category, eligible clinicians report on different IA measures, each worth a certain number of points. Each IA measure, or “activity”, carries a weight of either “high” and is worth 20 points, or “medium” and worth 10 points.  Of the 113 available IA measures, there are 27 activities weighted “high” and 91 “medium” weighted activities.  To achieve the 40 point maximum in the IA category, CRNAs can select a combination of medium and high weighted activities.

For CRNAs who qualify for the “special status”, as described in question two, the points earned for each activity is doubled. (e.g., high weight activities earn 40 points and medium weighted measures will each earn an EC 20 points). A vast majority of CRNAs will fall into the alternative weighted “special status” group and thus have their IA measures reweighted.  If reweight is applicable (option A), CRNAs will need to report on up to two of the possible 91 medium-weight activities (reweighted to 20 pts.), or find one appropriate high-weight activity (reweighted to 40 pts.). However, some CRNAs t that are part of a large (>15 ECs) multispecialty practice that choose the group reporting option and  are  categorized as a “patient-facing” group will need to report up to 4 IA measures under the standard weighting scheme (Option B).

To achieve the maximum possible 40 points for the Improvement Activity score, CRNAs have the following options: 

Option A: “Special Status” Reweight Scheme - *CRNAs with “special-status” as an individual or group practice getting reweight scheme in IA Category:

  • 1 high-weighted activity [27 available measures]  (1 x 40pts.)
  • 2 medium-weighted activities [91 available measures] (2 x 20pts.)

*This applies to any CRNA reporting as an individual clinician (non-patient facing), group reporting in a small group (<=15 ECs, group reporting in a large group (>15 ECs) whereby 75% or more of clinicians are in large non-patient facing group, and/or are located in rural or HPSA areas.

Option B: Standard Weighting Scheme – CRNAs who group report as part of a large (>15 ECs) multispecialty practice and categorized as “patient-facing”:

  • 2 high-weighted activities [27 available measures] (2 x 20pts.)
  • 1 high-weighted activity (20pts.) + 2 medium-weighted activities (2 x 10pts.)
  • 4 medium-weighted activities (4 x 10pts.)

Applicable only to CRNAs reporting as a group with more than 15 MIPS Eligible Clinicians billing under the same TIN and less than or equal to 75% of group encounters are patient-facing.

How does my performance in the IA Category affect my overall MIPS score?

In 2018, CMS finalized the Improvement Activities Category weight at 15% for all eligible clinicians participating in MIPS. While the Quality Performance Category weight is still a significant portion of the final MIPS composite score, the IA Category weight will always remain the same at 15%. Full participation in the Improvement Activities category earns forty points, making the possible IA Performance category contribution to your final MIPS score 15 points. Because the MIPS final score minimum threshold is set at 15 to avoid a payment penalty, earning full points in the IA category will suffice in avoiding the negative payment adjustment. However, participation in both Improvement Activities and the Quality category, which has a category weight between 50% and 85%, depending on MIPS status, is highly recommended in order to assure achievement of the 15 point final score threshold.

What is the reporting period for the IA category?

Each improvement activity must be completed and reported for a minimum of 90 consecutive days within the performance period of January 1, 2018 - December 31, 2018. Therefore, ECs have until October 2, 2018, to begin implementing Improvement Activities to report for MIPS in 2018. Eligible Clinicians must attest by indicating “Yes” to each activity that meets the 90-day requirement (activities that you performed for at least 90 consecutive days during the performance period of calendar year 2018).

What is attestation and how can I properly report my IAs?

Attestation is defined as the act of attending the execution of a document and bearing witness to its authenticity, by signing one's name to it to affirm that it is genuine. Eligible clinicians and groups only need to attest via the Quality Payment Program website that they completed the improvement activities they selected or should work with their vendor to determine the best way to submit their activities via a qualified clinical data registry (QCDR), a qualified registry, or their electronic health record system.

CRNAs may submit their improvement activities by attestation via the CMS Quality Payment Program website, a qualified clinical data registry (QCDR), a qualified registry, or, when possible, from their electronic health record system. You must attest by indicating “Yes” to each activity that meets the 90-day requirement (activities that you performed for at least 90 consecutive days during the performance period of calendar year 2018).

If a patient-facing group of 25 or more choose the CMS Web Interface group reporting option, they should refer to reporting specifications outlined within this program. More information can be found on the CMS MIPS Improvement Activities Fact Sheet

How long should I keep the documentation for my improvement activities?

Eligible clinicians are encouraged to retain documentation for 6 years as required by the CMS document retention policy. This guidance is as provided in the CMS Improvement Activities Fact Sheet. In 2017, CMS also provided MIPS Data Validation Criteria that outlined required data submission criteria and suggested documentation. An updated 2018 MIPS Data Validation Criteria for IA has not been produced by CMS at this time.

Why is using a QCDR unique in the Improvement Activities Category?

Participation in a QCDR has the added benefit of hosting approved QCDR Improvement Activities. Some QCDRs also offer enrollment and separate participation in a Patient Safety Organization (PSO), which is yet another approved Improvement Activity. While you are not required to participate and report through a QCDR that offers a PSO, many CRNAs can potentially meet all requirements for MIPS full participation in the IA category.  CRNAs can also choose Improvement Activities that are not associated with a QCDR.

If you choose to participate in MIPS via a QCDR, you must select and achieve each improvement activity separately. You will not receive credit for multiple activities just by selecting one activity that includes participation in a QCDR.  For further information about how to participate in an IA through a QCDR, you should contact the QCDR of your choice and identify which QCDR Improvement Activities they support.   

How do I choose Improvement Activities?

Individual ECs or group practices should determine which Improvement Activities are meaningful to their particular practice. While AANA has provided a short list of potential IA measures that may be applicable to CRNAs, not all measures are useful or applicable for every setting or practice. Additionally, modifications to MIPS Improvement Activities are eligible to undergo changes and revisions. ECs are ultimately responsible for selecting applicable measures that fit their practice and quality goals. Clinicians can choose from 113 included improvement activities under 9 subcategories:

  1. Expanded Practice Access
  2. Population Management
  3. Care Coordination
  4. Beneficiary Engagement
  5. Patient Safety and Practice Assessment
  6. Participation in an APM
  7. Achieving Health Equity
  8. Integrating Behavioral and Mental Health
  9. Emergency Preparedness and Response

Download the .zip file that includes the CMS List of 2018 Improvement Activities and Fact Sheet for resources and information.