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MIPS: Improvement Activities

MIPS: Improvement Activities
  • March 8, 2019
  • MIPS

MIPS: Improvement Activities

The MIPS Improvement Activities category measures the eligible clinician’s participation in activities that improve clinical practice or care delivery.  In 2019, this category is weighted at 15% of the individual clinician’s or group’s total MIPS score (while the Quality category accounts for the remaining 85% of the total score for PTs, OTs, and SLPs).

Over 100 MIPS Improvement Activities are divided into the following nine (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 (Alternative Payment Model)
  7. Achieving Health Equity
  8. Emergency Preparedness and Response
  9. Integrated Behavioral and Mental Health

Activities do not have to be selected from each category or from a certain number of categories. Activities should be chosen based on what is most appropriate and meaningful for the participating clinician’s or group’s practice.

Improvement Activities are designated by CMS as either high- or medium-weighted activities. High-weighted activities are worth 20 points; medium-weighted are worth 10 points. To earn full credit in this category, eligible clinicians or groups must report activities totaling 40 points:

  • 2 high-weighted activities, OR
  • 1 high- and 2 medium-weighted activities, OR
  • 4 medium-weighted activities.

Small practices (≤ 15 eligible clinicians) receive “double points” per activity and can achieve the requisite 40 points via 1 high-weighted activity or 2 medium-weighted activities.

A complete list of available Improvement Activities for 2019 can be found in the Resource Center on the CMS Quality Payment Program (QPP) website.

Examples of activities that may be applicable to an outpatient therapy practice include:

Activity ID & Name Description Weight
IA_CC_9: Implementation of practices/processes for developing regular individual care plans Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care. Medium
IA_CC_10: Care transition documentation practice improvements MIPS eligible clinician must document practices/processes for care transition with documentation of how the MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind during the first 30 days following a discharge. Examples: staff involved in the care transition, phone calls conducted in support of transition, home visits, patient access to their medical records, etc. Medium
IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of an improvement plan High
IA_BE_13: Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms Medium
IA_BE_15: Engagement of patients, family, caregivers in developing a plan of care Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology

 

Medium
IA_BE_21: Improved practices that disseminate appropriate self-management materials Provide self-management materials at an appropriate literacy level and in an appropriate language Medium
IA_PSPA_21: Implementation of fall screening and assessment programs Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., clinical decision support/prompts in EHR) Medium

Selected activities must be completed for 90 consecutive days during the performance period (e.g., calendar year 2019). The individual clinician or group must attest to completing the selected activities by submitting the attestation directly to CMS through a Qualified Registry or Qualified Clinical Data Registry (QCDR) with this capability or by logging in to the Quality Payment Program website and attesting to activity completion (e.g., selecting a “yes” response for each activity completed). If participating as a group, one individual can log in and attest on behalf of the group. Each activity can be reported only once during the performance period, unless otherwise specified within the activity description.

There are several improvement activities related to participation with a QCDR, such as FOTO or APTA’s Physical Therapy Outcomes Registry. To receive credit for these activities, clinicians must perform the activity for a minimum of a continuous 90-day period and attest to the activity via the login and attest submission mechanism or have the QCDR submit the specific activities on behalf of the clinician or group. Simply participating with a QCDR and having them submit quality data does not satisfy the Improvement Activity category requirements.

For many of the activities, it is up to the participating clinician or group to determine how best to implement and carry out the chosen activity, as this will likely vary based on the patient population served and the specific practice. CMS simply states that the participating clinician or group must select and implement the activities for a minimum of 90 consecutive calendar days during the performance year, and then attest that this has been done.

In addition, clinicians and groups that participate in MIPS must retain data and information (documentation) demonstrating compliance with the category requirements (whether Quality or Improvement Activities) for 6 years from the end of the MIPS performance period. For Improvement Activities, this “data and information” will vary based on the selected activity and the clinician or group. Documentation used by CMS to validate the activities, should CMS request to review it, should demonstrate “consistent and meaningful engagement within the period” for which the clinician/group attests.  On March 1, 2019, CMS posted updated information on improvement activities criteria in the QPP Resource Center, including “suggested documentation” to demonstrate activity completion and validation criteria.

Examples of documentation to demonstrate consistent and meaningful engagement:

  • Activity IA_BE_21 “Improved Practices that Disseminate Appropriate Self-Management Materials: Provide self-management materials at an appropriate literacy level and in an appropriate language.” Home exercise programs or other patient education materials issued during the episode of care would meet this requirement as long as it is done consistently and in accordance with the stated literacy and language requirements. This must be documented in the medical record.
  • Activity IA_PSPA_21 “Implementation of Fall Screening and Assessment Programs: Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors.” Use valid and reliable tools to identify patients at risk for falls (e.g., Berg, TUG, ABC, FES) and address modifiable risk factors in the course of treatment, documenting each patient’s results in the medical record. Also, progress made in the fall screening and assessment process after tool implementation should be documented (e.g., the practice’s overall improvement in identification and addressing of fall risk).
  • Activity IA_CC_9 “Implementation of Practices/Processes for Developing Regular Individual Care Plans: Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).” CMS suggests that the development of care plan templates and medical record documentation that demonstrates sharing the plan with the patient/caregiver, giving consideration to the patient’s goals, language and communication preferences and desired outcomes of care, would help meet the requirements of this activity. Therapy documentation should include adjustments to the treatment interventions and goals in therapist progress reports or updated plans of care and patient/caregiver education about the plan and expected outcomes.

In addition, documentation of the process or expectations (as is found in a policy, a performance improvement or QAPI program or in staff meeting minutes) around the selected Improvement Activities, would help demonstrate the activity’s implementation in your practice.

For more information on MIPS and the Improvement Activities category, please click here.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Quality, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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