Upcoming Webinars 

Disclaimer

The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Menu
Log in


Log in

MIPS Improvement Activities

Improvement activities show that clinicians are engaging in quality improvement efforts in their clinical practice. Improvement activities must be performed for 90 days or more during the performance year and are weighted either "medium" or "high" depending on the demands of the activity. To earn full credit in this category, eligible PTs and OTs must submit 1 of the following combinations of activities:

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

2020 Improvement Activities 

Sample Activities

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).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.

Category: Patient Safety and Practice Assessment           

Weight: Medium

Care transition documentation practice improvements           

In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient's preferences in mind (that is, a "patient-centered" plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.

Category: Care Coordination 

Weight: Medium

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.           

Category: Beneficiary Engagement   

Weight: High

Completion of an Accredited Safety or Quality Improvement Program       

Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:- The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;- The activity must have specific, measurable aim(s) for improvement;- The activity must include interventions intended to result in improvement;- The activity must include data collection and analysis of performance data to assess the impact of the interventions; and- The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information. An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).  

Category: Patient Safety And Practice Assessment           

Wight: Medium

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.  A timely manner is defined as within 10 business days for this activity.   

Category: Achieving Health Equity  

Weight: High

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).           

Category: Patient Safety and Practice Assessment           

Weight: Medium

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, such as:- Participation in multisource feedback; - 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;- Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;- Participation in Bridges to Excellence;- Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.     

Category: Patient Safety And Practice Assessment           

Weight: Medium

Improved Practices that Engage Patients Pre-Visit   

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient's appointment.  

Category: Beneficiary Engagement   

Weight: Medium

Promote Use of Patient-Reported Outcome Tools  

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.  

Category: Achieving Health Equity  

Weight: High

Provide Education Opportunities for New Clinicians      

MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.   

Category: Achieving Health Equity  

Weight: High

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.          

Category: Expanded Practice Access

Weight: Medium

Powered by Wild Apricot Membership Software