Improvement Activities Requirements

This performance category measures participation in activities that improve clinical practice.

Requirements may change each Performance Year (PY) due to policy changes, and for 2019 your requirements will be 15% of the final score.  This percentage can change due to Exception Applications, or Alternative Payment Model (APM) participation.

What Improvement Activities Data Should I Submit?

To earn full credit in this performance category, participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2019):  2 high-weighted activities, 1 high-weighted activity and 2 medium-weighted activities, or 4 medium-weighted activities.

UPDATED How Are Activities Scored?

High-weighted activities receive 20 points and medium-weighted activities receive 10 points.

Special Status

You will receive double points for each high or medium-weighted activity you submit if you are an individual clinician, group, or virtual group who holds any of these special statuses:  small practice, non-patient facing, Rural, or Health Professional Shortage Area (HPSA)

Patient-centered Medical Homes

If you are a participant in a recognized or certified patient-centered medical home or comparable specialty practice, you will earn the maximum Improvement Activity performance category score by attesting to this during the submission period. (For organizations with multiple practice sites, at least 50 percent of these locations must be recognized or certified patient-centered medical homes or comparable specialty practices to attest to this.)

CMS Study On Factors Associated With Reporting Quality Measures Study

Study participants receive full credit in the Improvement Activities performance category if they submit an application and successfully meet all of the study participation requirements.

UPDATED How Should I Submit Data?

Individual clinicians, groups, and virtual groups can log in and attest to their improvement activities measure data on  Improvement activities that measure data in an approved file format can be uploaded to by individual clinicians, groups, virtual groups, and third-party intermediaries.  Transmitting data through a computer-to-computer interaction, such as an API must be done by an authorized third-party intermediaries to perform a direct submission.

Third-Party Intermediaries

A third-party intermediary is an entity that collects and submits data on behalf of MIPS eligible clinicians – such intermediaries can be a qualified registry, a qualified clinical data registry (QCDR), a health IT vendor that obtains data from a MIPS eligible clinician’s CEHRT, or a CMS-approved survey vendor.  Certain CMS-approved third-party intermediaries also provide feedback to clinicians throughout the year to support and drive improvement. These are Qualified Clinical Data Registries, and Qualified Registries.

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