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

Reporting for Improvement Activities

MIPS 2018 Improvement Activities ComponentThe Improvement Activities performance component aims to measure provider engagement in activities that improve clinical practice. Categories within IA include ongoing care coordination, clinician and patient shared decision making, regular implementation of patient safety practices, and expanding practice access. Within the IA category, each activity is assigned either a high (20 points) or medium (10 points) weight.

  • 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 small practices OR rural practices to achieve full credit, only one high-value or two medium-value activities are required. CMS defines small practices as those consisting of 15 or fewer eligible clinicians. CMS defines rural practices as those where more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s TIN are designated in a ZIP code as a rural area or HPSA (based on the most recent Health Resources and Services Administration Area Health Resource File data set).

Those who completely fulfill the requirements for the Improvement Activity category will receive the maximum score in the Improvement Activity category and full credit toward their MIPS Final Score (15 points). Because for 2018 the performance threshold is set at 15 points, those who wish
to simply avoid a payment penalty can earn and secure 15 points in the IA category and thereby avoid a penalty in 2020 for their performance
in 2018.

The reporting requirement for the Improvement Activities category is fulfilled by simple attestation via a qualified registry, QCDR, an EHR, or the QPP Data Submission System. The ACS has two QCDRs, the Surgeon Specific Registry and the Metabolic and Bariatric Surgery Quality Improvement Program Data Registry, through which surgeons can also attest to IAs.

While IA is a new requirement, introduced in 2017, surgeons are likely already familiar with many of the activities included, such as maintenance of certification Part IV (MOC), use of the ACS Surgical Risk Calculator, participation in a QCDR, and registration with their state’s prescription drug monitoring program (PDMP). For a complete inventory of the IAs, please visit the CMS Improvement Activities page. The ACS has created a condensed list of surgically relevant IAs.

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.