MIPS and Improvement Activity Data

Nov 13, 2018 3:28:24 PM by Jody Lutz

Last week on the AffirmHealth Blog we discussed MIPS and PDMP Usage and promised a follow up on additional Improvement Activities. So this week we look at an Improvement Activities Data overview as well as a handful of activities potentially pertinent to providers prescribing opioids or other controlled substances.

Let’s start at the beginning…

What Improvement Activities Data Should I Submit?

To earn full credit in this category, participants must submit one of the following combinations of activities (each activity must be performed for 90 days or more during 2018).

  • 2 high-weighted activities
  • 1 high-weighted activity and 2 medium-weighted activities
  • At least 4 medium-weighted activities

Source: CMS

Bonus Points

Some Improvement Activities are marked as “CEHRT-Eligible,” meaning the activity is eligible for a 10% bonus points award in the promoting interoperability performance category.

 

Want more information on Improvement Activities? 

The American Academy of Family Physicians provides an excellent resource: MIPS: Explaining the Improvement Activities (IA) Performance Category as well as a 2018 MIPS Playbook.

Further clarification is provided in an infographic spread from the American College of Radiology. ACR states in their detailed summary:

The number of required activities depends on whether the group or individual is considered “patient facing” or “non-patient facing.” If an individual or group practice has billed more than 100 patient facing encounter codes in the past year, they will be considered patient facing. CMS has released the list of all patient facing encounter codes to help physicians determine their status. For more information, see ACR’s Patient Facing Clarification write-up.

For groups of more than 15 patient facing clinicians, medium-weighted activities count for 10 points each, and high-weighted activities are worth 20 points. For non-patient facing clinicians, groups of 15 or fewer clinicians, or those in rural or health professional shortage areas, point values are doubled so that medium-weighted activities are 20 points and high-weighted activities are worth 40 points. 

MIPS2

You may use any combination of activities that adds to 40 points.

Patient facing clinicians are required to attest to either two high-weighted Improvement Activities or four medium-weighted activities, while non-patient facing clinicians, groups of fewer than 15 participants and those in rural or health professional shortage areas only have to attest to one high-weighted activity or two medium-weighted activities. 

Source: American College of Radiology (ACR)

So now that we’ve gotten the general framework down – what can I or my practice actually do from an implementation standpoint? We breakdown a handful of high and medium weight activities below:

CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain

 

Subcategory Name: Patient Safety and Practice Assessment

Activity Weighting: High

Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Additional Pertinent Resources:

 

Subcategory Name: Patient Safety and Practice Assessment

Activity Weighting: Medium

Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.

Additional Pertinent Resources:

 

Subcategory Name: Patient Safety and Practice Assessment

Activity Weight: Medium

Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.

Additional Pertinent Resources:

 

Subcategory Name: Patient Safety and Practice Assessment

Activity Weight: Medium

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).

Additional Pertinent Resources:

 

Subcategory Name: Population Management

Activity Weight: Medium

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.

Additional Pertinent Resources:

 

Subcategory Name: Behavioral and Mental Health

Activity Weight: Medium

Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.

Additional Information: Suggested documentation includes a patient chart record or report generated from certified EHR, QCDR, clinical registry or documentation from medical charts showing consistent practice of tobacco screening protocols for patients with co-morbid conditions pertaining to behavioral/mental health and at risk factors for tobacco dependence.

Additional Pertinent Resources:

 

Subcategory Name: Behavioral and Mental Health

Activity Weight: Medium

Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.

Additional Pertinent Resources:

 

When does the MIPS Performance Year take place?

Just a reminder, per CMS the MIPS Performance Year begins on January 1 and ends on December 31 of each year. Program participants must report data collected during one calendar year by March 31 of the following calendar year. For example, program participants who collected data in 2017 must report their data by March 31, 2018 to be eligible for a payment increase and to avoid a payment reduction in 2019.

Providers can visit the CMS site and enter their National Provider Number (NPI) to check their yearly participation status. 

At AffirmHealth, we understand that developing prescribing and practice protocols takes considerable time and effort. We partner with organizations to build and implement risk-informed protocols tailored to the practice. Our new product Shield is a software platform to help manage, facilitate and measure prescribing compliance using those protocols. We would welcome the opportunity to partner with your organization.
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