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

Improvement Activities Performance Category

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. Those who completely fulfill the requirements for the IA category will receive the maximum score in the IA category, which will earn them 15 points towards their MIPS overall score.

  • To receive full credit, most surgeons must select and attest to having completed up to four activities over at least 90 consecutive days in the 12-month performance period 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. 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 billing under the individual Merit-based Incentive Payment System-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.
  • Beginning in 2020, surgeons who report IA in as part of a group practice (i.e., TINS) can only attest to an improvement activity if at least 50% of the clinicians in the group or virtual group complete the same activity during any continuous 90-day period during the performance year. This represents a significant change from previous years when a TIN could receive a credit for an IA so long as a single clinician attested to the activity.

The reporting requirement for the Improvement Activities category is fulfilled by simple attestation via a qualified registry, a Qualified Clinical Data Registry, an Electronic Health Record, or manual attestation through 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 Qualified Registries where surgeons can attest to IAs—the Surgeon Specific Registry™ and the Metabolic and Bariatric Surgery Quality Improvement Program Data Registry.

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 2020.