American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

How to Participate in Improvement Activities


Improvement Activities (IA) for the Merit-based Incentive Payment System (MIPS) is worth 15 percent of the MIPS final score. IA is a new type of activity and is not based on a previous Centers for Medicare & Medicaid Services (CMS) program. However, surgeons will be familiar with many of the activities included.

For 2017 only, physicians can avoid a MIPS penalty by attesting to having completed a single activity for 90 days. Physicians who fully report all MIPS components for 90 days or up to a full calendar year may earn an incentive payment based on their performance. Learn more about the Pick Your Pace reporting options for 2017.

How to Successfully Report IA

Each activity is assigned a point value of either 20 points (high value) or 10 points (medium value). The reporting requirement for IA is fulfilled by simple attestation via a registry, a Qualified Clinical Data Registry (QCDR), or a portal on the CMS website. To receive full credit, most surgeons must select and attest to having completed between two and four activities for a total of 40 points for a minimum of 90 days.

Small practices can achieve full credit by reporting only one high-value or two medium-value activities. CMS defines small practices as those with fewer than 15 providers, or those in a rural or health professional shortage area.

A comprehensive list of all 92 improvement activities can be found on the CMS QPP IA web page.

Below is a list of examples from the CMS list of activities that may be more relevant to surgeons:

  • Use of a QCDR to generate regular performance feedback. (20 points)
  • Participation in a QCDR, clinical data registries, or other registries run by other government agencies or private entities such as a hospital or medical or surgical society. (10 points)
  • Provision of episodic care management, including management across transitions and referrals that could include routine and timely follow-up to hospitalizations and ED visits and/or managing care intensively through new diagnoses, injuries and exacerbations of illness. (10 points)
  • Provision of specialist reports back to referring providers to close the referral loop. (10 points)
  • Timely communication of test results defined as timely identification of abnormal test results with timely follow-up. (10 points)
  • Participation in a QCDR, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement. (10 points)
  • Bilateral exchange of necessary patient information to guide patient care that could include participation in a health information exchange or use of structured referral notes. (10 points)
  • Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities. (10 points)
  • Use of evidence-based decision aids to support shared decision-making. (10 points)
  • Participation in Maintenance of Certification Part IV. (10 points)
  • Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. (10 points)
  • Consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II opioid prescription that lasts for longer than three days. (20 points)
  • Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the American College of Surgeons Surgical Risk Calculator Surgical Risk Calculator. (10 points)
  • Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. (20 points)

Attest Using ACS Registries

The ACS has two registries which have been approved by CMS. The ACS Surgeon Specific Registry (SSR) is a qualified registry as well as a QCDR and the ACS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a QCDR. Both of these ACS registries allow surgeons to attest to having completed Improvement Activities.

For more information, visit the CMS QPP Improvement Activities web page, or contact Bobby Kopp at or 202-672-1506.