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

MIPS 2020 Improvement Activities Options through the SSR

The Surgeon Specific Registry (SSR) has been approved by the CMS to provide MIPS Improvement Activities (IA) through registry-based reporting for the 2020 performance year. Eligible clinicians (ECs), including surgeons, may attest to and submit IA data through the SSR for 2020 MIPS with 73 surgically relevant IAs to choose from.

Full List of Available MIPS 2020 Improvement Activities in SSR

Reporting Requirements for 2020 Improvement Activities

Each IA must be attested to for a minimum of 90 consecutive days to earn full credit on each IA. To earn the maximum score for the IA component of MIPS, a surgeon must attest to 40 points worth of IAs, and each IA is assigned one of two weightings:

  • High (20–40 points)
  • Medium (10–20 points)

How many IAs an individual surgeon must attest to and the amount of points an IA is worth is then dependent on the size of the group for which the surgeon is a part of:

  • Individual surgeons in groups with more than 15 clinicians must select from one of the following combinations (high-weighted activities = 20 points; medium-weighted activities = 10 points):
    • 2 high-weighted activities, or
    • 1 high-weighted activity and 2 medium-weighted activities, or
    • Up to 4 medium-weighted activities
  • Individual ECs in groups with 15 or fewer clinicians, in a small practice or a rural setting, must select from one of the following combinations (high-weighted activities = 40 points; medium-weighted activities = 20 points):
    • 1 high-weighted activity, or
    • 2 medium-weighted activities

Beginning in 2020, surgeons who report IAs as part of a group practice (i.e., TINS) can only attest to an improvement activity if at least 50% of the ECs 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.