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

Reporting for Improvement Activities

Improvement Activities 15%The Improvement Activities (IA) 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.

  • 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. The Centers for Medicare and Medicaid Services (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 National Provider Identifiers (NPIs) billing under the individual Merit-based Incentive Payment System (MIPS)-eligible clinician or group’s Taxpayer Identification Number (TIN) are designated in a ZIP code as a rural area or health professional shortage areas—based on the most recent Health Resources and Services Administration Area Health Resource File data set.

Those who completely fulfill the requirements for the IA category will receive the maximum score in the IA category, which will earn them half of the points needed to meet the 2019 MIPS performance threshold (30 points) and avoid a payment penalty for 2021.

The reporting requirement for the Improvement Activities category is fulfilled by simple attestation via a qualified registry, a Qualified Clinical Data Registry (QCDR), an electronic health record, or the Quality Payment Program (QPP) Data Submission System. No supporting documentation is required at the time of attestation, although CMS encourages clinicians to keep documentation records on file in case of an audit. The ACS offers two QCDRs where surgeons can attest to IAs—the Surgeon Specific Registry and the Metabolic and Bariatric Surgery Quality Improvement Program Data Registry.

While IA was a new requirement, introduced in 2017, most surgeons are 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, visit the CMS Improvement Activities page. The ACS has created a condensed list of surgically relevant IAs, available for attestation through the SSR.

Attest Using ACS Registries

The ACS has two CMS-approved registries in 2019. The ACS Surgeon Specific Registry (SSR) meets the requirements of a qualified registry and a QCDR, while the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is designated as a QCDR. Both of these ACS registries allow surgeons to attest to having completed IAs. 

CMS also offers many resources on their QPP website, and is a great resource for learning about and selecting Quality measures, Promoting Interoperability measures, and Improvement Activities for reporting in 2019.