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

MIPS 2017 Improvement Activities Options through the SSR

The Surgeon Specific Registry (SSR) has been approved by the Centers for Medicare & Medicaid Services (CMS) to provide Merit-based Incentive Payment System (MIPS) Improvement Activities (IA) through registry-based reporting for the 2017 program year. Eligible clinicians** (ECs) may attest to and submit IA data through the SSR for 2017 MIPS with 72 surgically relevant IAs to choose from.

To earn the maximum score for the IA component for Full Year MIPS participation, an EC 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 EC must attest to and the amount of points an IA is worth is then dependent on the size of the group for which the EC is a part of:

  • Individual ECs 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
    • 1 high-weighted activity and 2 medium-weighted activities
    • 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
    • 2 medium-weighted activities

Each IA must be attested to for a minimum of 90 days to earn full credit. Download the full list of IAs with suggested documentation in case of CMS audit.

**For the 2017 and 2018 MIPS performance periods, the following clinician types can participate in MIPS: physicians; physician assistants (PAs); nurse practitioners (NPs); clinical nurse specialists; certified registered nurse anesthetics; and any clinician group that includes one of the professionals listed above.

IA Subcategory

IA Name and Description

Weighting

Eligible for ACI Information Bonus

Expanded Practice Access

Provide 24/7 access to MIPS eligible clinicians or groups who have real-time access to patient’s medical record
Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following: Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care); Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e- visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.

High

Yes

Expanded Practice Access

Use of telehealth services that expand practice access
Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults, or teleaudiology pilots that assess ability to still deliver quality care to patients.

Medium

 

Expanded Practice Access

Collection and use of patient experience and satisfaction data on access
Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.

Medium

 

Expanded Practice Access

Additional improvements in access as a result of QIN/QIO TA
As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).

Medium

 

Population Management

Participation in systematic anticoagulation program
Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program) for 60 percent of practice patients in the transition year and 75 percent of practice patients in year 2 who receive anticoagulation medications (warfarin or other coagulation cascade inhibitors).

High

 

Population Management

Anticoagulant management improvements
MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities: Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program. The performance threshold will increase to 75 percent for the second performance year and onward. Clinicians would attest that, 60 percent for the transition year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.

High

Yes

Population Management

RHC, HIS or FQHC quality improvement activities
Participating in a Rural Health Clinic (RHC), Indian Health Service (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.

High

 

Population Management

Use of toolsets or other resources to close healthcare disparities across communities
Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Medium

 

Population Management

Use of QCDR for feedback reports that incorporate population health
Use of a QCDR to generate regular performance feedback that summarizes local practice patterns and treatment outcomes, including for vulnerable populations.

High

 

Population Management

Participation in CMMI models such as Million Hearts Campaign
Participation in CMMI models such as Million Hearts Cardiovascular Risk Reduction Model Campaign.

Medium

 

Population Management

Participation in population health research
Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.

Medium

 

Population Management

Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Medium

 

Population Management

Implementations of episodic care management practice improvements
Provide episodic care management, including management across transitions and referrals that could include one or more of the following: Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or Managing care intensively through new diagnoses, injuries and exacerbations of illness.

Medium

Yes

Population Management

Implementations of medication management practice improvements
Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/or Conduct periodic, structured medication reviews.

Medium

Yes

Care Coordination

Implementation of use of specialist reports back to referring clinician or group to close referral loop
Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group to close the referral loop or where the referring MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology.

Medium

Yes

Care Coordination

Implementation of improvements that contribute to more timely communication of test results
Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.

Medium

 

Care Coordination

Implementation of additional activity as a result of TA for improving care coordination
Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.

Medium

 

Care Coordination

TCPI participation
Participation in the CMS Transforming Clinical Practice Initiative.

High

 

Care Coordination

CMS partner in Patients Hospital Improvement Innovation Networks
Membership and participation in a CMS Partnership for Patients Hospital Engagement Network.

Medium

 

Care Coordination

Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).

Medium

 

Care Coordination

Regular training in care coordination
Implementation of regular care coordination training.

Medium

 

Care Coordination

Implementation of documentation improvements for practice/process improvements
Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).

Medium

Yes

Care Coordination

Implementation of practices/processes for developing regular individual care plans
Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).

Medium

Yes

Care Coordination

Care transition documentation practice improvements
Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient- centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).

Medium

 

Care Coordination

Care transition standard operational improvements
Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or Partner with community or hospital-based transitional care services.

Medium

 

Care Coordination

Practice improvements for bilateral exchange of patient information
Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: Participate in a Health Information Exchange if available; and/or Use structured referral notes.

Medium

Yes

Beneficiary Engagement

Use of QCDR to support clinical decision making
Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.

Medium

 

Beneficiary Engagement

Engagement with QIN-QIO to implement self-management training programs
Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.

Medium

 

Beneficiary Engagement

Engagement of patients through implementation of improvements in patient portal
Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.

Medium

Yes

Beneficiary Engagement

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.

High

 

Beneficiary Engagement

Participation in a QCDR, that promotes use of patient engagement tools
Participation in a QCDR, that promotes use of patient engagement tools.

Medium

 

Beneficiary Engagement

Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive
Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.

Medium

 

Beneficiary Engagement

Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement
Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.

Medium

 

Beneficiary Engagement

Participation in a QCDR, that promotes implementation of patient self-action plans
Participation in a QCDR, that promotes implementation of patient self-action plans.

Medium

 

Beneficiary Engagement

Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan
Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.

Medium

 

Beneficiary Engagement

Use evidence-based decision aids to support shared decision-making
Use evidence-based decision aids to support shared decision-making.

Medium

 

Beneficiary Engagement

Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms
Regularly assess the patient experience of care through surveys, advisory councils, and/or other mechanisms.

Medium

 

Beneficiary Engagement

Engage patients and families to guide improvements in the system of care
Engage patients and families to guide improvement in the system of care.

Medium

 

Beneficiary Engagement

Engagement of patients, family and caregivers in developing a plan of care
Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.

Medium

Yes

Beneficiary Engagement

Evidence-based techniques to promote self-management into usual care
Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.

Medium

 

Beneficiary Engagement

Use of tools to assist patient self-management
Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).

Medium

 

Beneficiary Engagement

Provide peer-led support for self-management
Provide peer-led support for self-management.

Medium

 

Beneficiary Engagement

Use group visits for common chronic conditions (e.g., diabetes)
Use group visits for common chronic conditions (e.g., diabetes).

Medium

 

Beneficiary Engagement

Implementation of condition-specific chronic disease self-management support programs
Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.

Medium

 

Beneficiary Engagement

Improved practices that disseminate appropriate self-management materials
Provide self-management materials at an appropriate literacy level and in an appropriate language.

Medium

Yes

Beneficiary Engagement

Improved practices that engage patients pre-visit
Provide a pre-visit development of a shared visit agenda with the patient.

Medium

 

Patient Safety and Practice Assessment

Participation in an AHRQ-listed patient safety organization
Participation in an AHRQ-listed patient safety organization.

Medium

 

Patient Safety and Practice Assessment

Participation in MOC Part IV
Participation in Maintenance of Certification Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.

Medium

 

Patient Safety and Practice Assessment

Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity
For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS®.

Medium

 

Patient Safety and Practice Assessment

Administration of the AHRQ Survey of Patient Safety Culture
Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient- safety/patientsafetyculture/index.html)

Medium

 

Patient Safety and Practice Assessment

Annual registration in the Prescription Drug Monitoring Program
Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.

Medium

 

Patient Safety and Practice Assessment

Consultation of the Prescription Drug Monitoring program
Clinicians would attest that 60 percent for the first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days.

High

 

Patient Safety and Practice Assessment

Use of QCDR data for ongoing practice assessment and improvements
Use of QCDR data, for ongoing practice assessment and improvements in patient safety.

Medium

 

Patient Safety and Practice Assessment

Use of patient safety tools
Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator.

Medium

 

Patient Safety and Practice Assessment

Participation in CAHPS or other supplemental questionnaire
Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).

High

 

Patient Safety and Practice Assessment

Participation in private payer CPIA
Participation in designated private payer clinical practice improvement activities.

Medium

 

Patient Safety and Practice Assessment

Participation in Joint Commission Evaluation Initiative
Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.

Medium

 

Patient Safety and Practice Assessment

Participation in Bridges to Excellence or other similar program
Participation in other quality improvement programs such as Bridges to Excellence.

Medium

 

Patient Safety and Practice Assessment

Implementation of antibiotic stewardship program
Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics.

Medium

 

Patient Safety and Practice Assessment

Use decision support and standardized treatment protocols
Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.

Medium

Yes

Patient Safety and Practice Assessment

Implementation of analytic capabilities to manage total cost of care for practice population
Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following: Train appropriate staff on interpretation of cost and utilization information; and/or Use available data regularly to analyze opportunities to reduce cost through improved care.

Medium

 

Patient Safety and Practice Assessment

Measurement and improvement at the practice and panel level
Measure and improve quality at the practice and panel level that could include one or more of the following: Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.

Medium

 

Patient Safety and Practice Assessment

Implementation of formal quality improvement methods, practice changes or other practice improvement processes
Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: Train all staff in quality improvement methods; Integrate practice change/quality improvement into staff duties; Engage all staff in identifying and testing practices changes; Designate regular team meetings to review data and plan improvement cycles; Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families.

Medium

 

Patient Safety and Practice Assessment

Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.

Medium

 

Patient Safety and Practice Assessment

Implementation of fall screening and assessment programs
Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).

Medium

 

Achieving Health Equity

Engagement of new Medicaid patients and follow-up
Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.

High

 

Achieving Health Equity

Leveraging a QCDR to standardize processes for screening
Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.

Medium

Yes

Achieving Health Equity

Leveraging a QCDR to promote use of patient-reported outcome tools
Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).

Medium

 

Achieving Health Equity

Leveraging a QCDR for use of standard questionnaires
Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).

Medium

 

Emergency Response and Preparedness

Participation on Disaster Medical Assistance Team, registered for 6 months
Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.

Medium

 

Emergency Response and Preparedness

Participation in a 60-day or greater effort to support domestic or international humanitarian needs
Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.

High

 

Integrated Behavioral and Mental Health

Electronic Health Record Enhancements for BH data capture
Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).

Medium

Yes