Part of the MIPS program is improvement activities. There are two weights of improvement activities High and Medium. High weight activities are worth 20 points and Medium Weight activities are worth 10 points.
There is a special bonus for small practices, the value of the improvement activities is doubled for small practices. For a small practice High weight activities are worth 40 points and Medium Weight activities are worth 20 points. A small practice is practice with 15 individual NPI numbers in the same Tax ID.
The maximum score you can achieve for Improvement Activities is 40 points. For Large Practices this can be achieved with:
- • 2 High Weight Activities (2 x 20)
- • or 4 Medium Weight Activities (4 x 10)
- • or 1 High Weight and 2 Medium Weight Activity (1 x 20 + 2 x 10)
For small practices this can be achieved with:
- • 1 High Weight Activities (1 x 40)
- • or Medium Weight Activities (2 x 10)
For 2024 there are many activities you can choose from, and you can view the whole list in the resource center at https://qpp.cms.gov. For most practices I recommend
Advance Care Planning. This dovetails very nicely with the MIPS Quality Measure of Advance Care Plan. This is a Medium Weight Activity It involves:
Implementation of practices/processes to develop advance care planning that includes:
- • documenting the advance care plan or living will within the medical record,
- • educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement,
- • educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation,
- • as well as informing clinicians of the healthcare policy side of advance care planning.
Implementation of fall screening and assessment programs. This dovetails very nicely with Measure 155 Fall Risk Plan of Care. This is also a Medium Weight Activity. It involves:
- • 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 the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).
- • If your EHR does not have a Clinical Decision Support Prompt, then make sure you review medications each visit and if the patient is on a medication that increases fall risk then do a fall screening assessment
- • This will also help you hit quality measure 130 – Review Medications
If you are a small practice, with these two improvement activities you have now met your requirement for this component of MIPS.
Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record. This is a High Weight Activity and requires an Electronic Medical Record. It involves:
- • Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:
- • Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);
- • Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group
This is something that is probably in place for larger groups and now both small and large groups have all of the activities they need to get full points in improvement activities.
To log your activities in Registry Clearinghouse, click on the left menu item Improvement Activities, Scroll through the list of activities and check the ones you are meeting You want to select all providers and then hit Save. You are now ready to report your improvement activities to CMS.
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