Your QI Projects and MIPS Improvement Activities
Improving your clinical practice and patient care delivery is a high priority for you and your team. The quality improvement projects undertaken by your team in 2022 likely can earn you points in the Improvement Activities performance category of CMS’ Merit-based Incentive Payment System (MIPS).
What is MIPS?
With the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the Medicare Sustainable Growth Rate formula was repealed and replaced with the Quality Payment Program (QPP), CMS’ value-based purchasing program. Eligible clinicians can participate in the QPP via one of two pathways: the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). The majority of eligible clinicians report to the QPP via the MIPS pathway.
MIPS is comprised of four performance categories: Quality, Cost, Promoting Interoperability, and Improvement Activities. Each category has specific requirements and by fulfilling those requirements achievement points are earned toward a clinician or group’s final score, which is used to determine a positive, neutral, or negative payment adjustment. A clinician or group must earn at least 75 points for a total score via reporting for the 2022 performance year to avoid a negative payment adjustment.
To look up your MIPS eligibility status on CMS’ QPP website select here. All you need is your NPI and two minutes. Make sure you are checking your status for the 2022 performance year.
What is the Improvement Activities performance category?
The Improvement Activities performance category looks at a clinician or group’s engagement in clinical activities intended to improve clinical practice and patient care delivery that are likely to lead to better outcomes. This performance category is weighted at 15% of your total MIPS score so a clinician or group can earn up to 15 points by attesting to having completed improvement activities recognized by CMS as MIPS improvement activities. Download a list of MIPS improvement activities from the Resource Library on the QPP website. You can filter the list of resource document by choosing Performance Year: 2022, QPP Track: MIPS, and Performance Category: Improvement Activities.
Practices can earn up to 40 points by attesting to completion of high- and medium-weighted activities. Practices with 16 or more eligible clinicians must report two high-weighted activities or one high-weighted and two medium-weighted activities or four medium weighted activities to earn full credit in the performance category. Small practices, defined by CMS as 15 or fewer eligible clinicians, as well as practices located in rural and health professional shortage areas must report one high-weighted activities or two medium-weighted activities to earn full credit in the performance category. Each improvement activity must take place over a minimum of 90 days within the performance year; so, the time is now to determine which activities you are conducting meet CMS criteria and course correct as needed.
Does ASGE programming fulfill the requirements of any MIPS improvement Activities?
Yes! The following programs supported by ASGE are recognized by CMS as MIPS improvement activities.
- Achieving and maintaining honoree status in the ASGE Endoscopy Unit Recognition Program meets the criteria for the medium-weighted improvement activity IA_PSPA_18: Measurement and improvement at the practice and panel level.
- Participating in ASGE’s GI Operations Benchmarking meets the criteria for the medium-weighted improvement activity IA_PSPA_17: Implementation of analytic capabilities to manage total cost of care for practice population.
- Participating in ASGE’s Skills Training Assessment Reinforcement (STAR) Certificate Program meets the criteria for the medium-weighted improvement activity IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program To see upcoming STAR course select here.
- CMS lists various improvement activities for leveraging participation in a qualified clinical data registry (QCDR). The GIQuIC registry, sponsored by ASGE and the American College of Gastroenterology, is recognized by CMS as a QCDR. Units registered and actively participating in GIQuIC no later than June 30, 2022, can report improvement activities using their data in GIQuIC.