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MIPS - Improvement Activities

This category will account for 15% of the total MIPS score.

An Improvement Activity is one “that MIPS eligible clinicians, organizations and other relevant stakeholders identify as improving clinical practice or care delivery and … is likely to result in improved outcomes.”

The list of 113 Improvement Activities that are eligible for inclusion in this performance category can be found on the CMS website. Note that there are several subcategories with each activity weighted as either high (worth 20 points) or medium (worth 10 points), and that several contribute to an Advancing Care Information bonus, since they require the use of Certified EHR Technology (CEHRT). 

The 9 subcategories are:

  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

A total of 40 points can be achieved in this category, however, small practices (≤15 ECs), or practices located in designated rural or health professional shortage areas, will receive double points for each activity. 

Eligible Clinicians in a CMS-recognized Patient Centered Medical Home (PCMH) or Patient Centered Specialty Practice (PCSP) will receive credit towards this performance category if attesting to participation in one of the approved models. CMS recognizes a PCMH as one that meets one of the following criteria:

  • The practice has received accreditation from one of four accreditation organizations that are nationally recognized:
    • The Accreditation Association for Ambulatory Health Care;
    • The National Committee for Quality Assurance (NCQA);
    • The Joint Commission; or
    • The Utilization Review Accreditation Commission (URAC);
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model (Note: CMS has defined what a Medical Home Model is, but the only available model at this time is CPC+.);
  • The practice is a comparable specialty practice that has received the NCQA Patient-Centered Specialty Recognition; or
  • The practice has received certification or accreditation as a PCMH or comparable specialty practice from a national program or from a regional or state program, private payer or other body that administers PCMH accreditation and certifies 500 or more practices for PCMH accreditation or comparable specialty practice certification.

Below is a summary of the requirements for this category:

Policy 2017 (Transition Year) 2018 (Year 2)
Measures/Activities Required

Most participants: Up to 4 improvement activities

Groups with fewer than 15 participants or in rural or health professional shortage areas: Up to 2 activities

No change
Activities Available 92 112
Special Options PCMH & PCSP - Full credit* Overall no change, but PCMH and PCSP TINs must have 50% of practices certified/recognized
Reporting/Scoring Attestation Attestation
Performance Period 90 Days 90 Days
Weight 15% 15%

*If one practice in the TIN is a PCMH or PCSP