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The MIPS Improvement Activities Category is one of the four categories comprising the Centers for Medicare and Medicaid Services (CMS)'s Merit-based Incentive Payment System (MIPS). MIPS is part of the CMS Quality Payment Program (QPP), in which eligible providers are required to participate during 2021 to avoid a negative impact on the physician fee payment for the year of 2023. The last continuous 90-day period to perform an improvement activity begins October 3, 2021.

This blog post provides a summary on the MIPS Improvement Activities Category and an overview on how WoundReference can support eligible clinicians and groups participating in MIPS.  For more information on MIPS see topic "MIPS in Wound Care and Hyperbaric Medicine". For an update on Quality in wound care see topic "Quality in Wound Care". 

For Quality Payment Program Flexibilities in Response to COVID-19 for CY 2019 and CY 2020 see this CMS Fact Sheet.

Apply for the Quality Payment Program Exception Applications by February 1, 2021

Who needs to complete MIPS Improvement Activities?

All MIPS eligible providers who bill Medicare Part B. Find out more about provider eligibility on the topic "MIPS in Wound Care and Hyperbaric Medicine". 

For group reporting, a group or virtual group can attest to an activity when at least 50% of the clinicians in the group or virtual group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year.

What are the reporting requirements for the Improvement Activities category?

Participants must submit one of the following combinations of activities, for a total of 40 points (each activity must be performed for 90 continuous days or more during 2020)

  • 2 high-weighted activities, or
  • 1 high-weighted activity and 2 medium-weighted activities, or
  • 4 medium weighted activities
Activity WeightsPoints Points if eligible provider has a 'Special Status'*
Medium 1020

* Special status: clinicians in small, rural, or underserved practices or with non-patient facing clinicians or groups

Note: a MIPS eligible clinician who is in a practice that is certified and recognized as "patient-centered medical home" (PCMH) earns 40 points (100% of the Improvement Activity Score). This credit is not granted automatically, eligible clinician or practices need to attest this status of PCMH. PCMH is a Medicaid medical home model, Medical home model or comparable specialty practice. See definition of "patient-centered medical home" in this CMS document.

Scoring for the Improvement Activities category

Improvement Activities are scored as follows:

  • Improvement activities performance category score = Total number of points scored for completed activities / Total maximum number of points (40 points) x 100
  • Maximum score cannot exceed 100%. Forty (40) points or 100% of the Improvement Activity category is equivalent to 15% of the total MIPS score
  • Besides Improvement Activities, which can comprise up to 15% of the total MIPS 2021 score, the other categories of the total MIPS score are Quality (40% of the total score), Promoting Interoperability (25%) and Cost (20%). 

Where can I find the MIPS Improvement Activities? 

What’s New with Improvement Activities in 2021?

  • Medicare is continuing the high-weighted COVID-19 Clinical Data Reporting with or without Clinical Trial (IA_ERP_3) improvement activity for performance year (PY) 2021.
  • Medicare modified 2 existing improvement activities: Engagement of Patient through Implementation of Improvements in Patient Portal (IA_BE_4) and Comprehensive Eye Exams (IA_AHE_7).
  • Medicare removed 1 activity that is obsolete: CMS Partner in Patients Hospital Engagement Network (IA_CC_5).

How do I attest for Improvement Activities? 

  • MIPS eligible clinicians, groups and virtual groups may submit Improvement Activities data using multiple data submission types, provided that the individual/ clinician/ group use the same and constant identifier(s) for all performance categories and all data submissions.
  • To attest for an Improvement Activity, simply answer "yes" to each Improvement Activity that meet the 90-day requirement. An eligible clinician reporting as a group can attest for an Improvement Activity as long as one clinician in his/her group participated in the Improvement Activity during 90 consecutive days in 2021.
  • Proof of participation in an Improvement Activity varies according to the activity and is stated on the list of improvement activities for 2020. Eligible providers should keep the proof in case of a CMS audit for a period of 6 years as evidence of attestation. The 2021 Data Validation Criteria will be available later in the performance period. On the Quality Payment Program Resource Library, find the MIPS Data Validation Criteria easily by searching for “Validation” without filters.
  • Common examples of documentation may include, but are not limited to:
    • Screenshot or digital capture of relevant information supporting the attestation.
    • Improvement plans and/or outlines supporting the interventional strategies/processes implemented to meet the intent of the improvement activity.
    • Electronic Health Record Report: Retain a copy of documentation relevant to the chosen improvement activity as evidence of attestation.

Note: data collection applies to all patients, not only Medicare patients, but eligible providers are required to attest only for medicare patients

How can WoundReference help eligible clinicians and groups perform well in MIPS Improvement Activities? 

Just by using WoundReference’s decision support protocols and tools eligible clinicians and groups can easily meet the number of measures required in the Improvement Activities category. The table below compiles some of the 2020 Improvement Activities that can easily be completed with WoundReference. 

WoundReference enabler/ tool ID/Subcategory nameActivity name and descriptionWeightValidationSuggested Documentation (inclusive of dates during the selected continuous 90-day or year long reporting period)

TeleVisit Tool 2.0

IA_EPA_2/ 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.

Documented use of telehealth services and participation in data analysis assessing provision of quality care with those services

NOTE: For the purposes of this IA, telehealth services include a “real time” interaction and may be obtained over the phone, online, etc. and are not limited to the Medicare reimbursed telehealth service criteria.

1) Use of Telehealth Services - Documented use of telehealth services through: a)  claims adjudication (may use G codes to validate); b) EHR or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient; and 

2) Analysis of Assessing Ability to Deliver Quality of Care - Participation in or performance of quality improvement analysis showing delivery of quality care to patients through the telehealth medium (e.g. Excel spreadsheet, Word document or others) 

TeleVisit Tool 2.0 with built in specialist documentation templates
IA_CC_1/ 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 EHR technology.
MediumFunctionality of providing information by specialist to referring clinician or inquiring clinician receives and documents specialist report

1) Specialist Reports to Referring Clinician - Sample of specialist reports reported to referring clinician or group (e.g. within EHR or medical record); or 

2) Specialist Reports from Inquiries in Certified EHR - Specialist reports documented in inquiring clinicians certified EHR or medical records

Wound Care and Hyperbaric Oxygen Therapy Knowledge Base condition-specific care plan templates IA_CC_9/ Care Coordination
Implementation of practices/processes for developing regular individual care plans. Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient's goals and priorities, as well as desired outcomes of care.
MediumIndividual care coordination plans including a discussion on care are regularly developed and updated for at-risk patients and shared with beneficiary or caregiver 

1) Individual Care Plans for At-Risk Patients - Documented practices/processes for developing regularly individual care plans for at-risk patients, e.g., template care plan; and 

2) Use of Care Plan with Beneficiary - Patient medical records demonstrating  care plan being shared with beneficiary or caregiver, including consideration of a patient's goals and priorities, social risk factors, language and communication preferences, physical or cognitive limitations, as well as desired outcomes of care

Wound Care and Hyperbaric Oxygen Therapy Knowledge Base, algorithms/ pathways, checklists, order setsIA_BE_12/ Beneficiary Engagement
Use evidence-based decision aids to support shared decision-making. Use evidence-based decision aids to support shared decision-making.
MediumUse of evidence based decision aids to support shared decision-making with beneficiary
Documentation (e.g. checklist, algorithms, tools, screenshots) showing the use of evidence-based decision aids to support shared decision-making with beneficiary
Go-no-Go Hyperbaric Risk Assessment ToolIA_PSPA_8/ Patient Safety & Practice Assessment
Use of patient safety tools. In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice. Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar too
MediumUse of systems, tools and strategies implemented by specialty practices, for tracking specific meaningful patient safety and practice assessment (e.g., ORT or similar tools are permitted).
Documentation of the use of patient safety tools, e.g. surgical risk calculator,  evidenced based protocols such as Enhanced Recovery After Surgery (ERAS) protocols and ORT or similar tools are permitted.  The CDC Guide for Infection Prevention for Outpatient Settings, or predictive algorithms, that assist specialty practices in tracking specific patient safety measures meaningful to their practice to meet the intent of the IA.
Wound Care and Hyperbaric Oxygen Therapy  Knowledge Base, algorithms/ pathways, checklists, order sets
IA_PSPA_16/ Patient Safety and Practice Assessment
Use of decision support and standardized treatment protocols. Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.
MediumUse of decision support and treatment protocols to manage workflow in the team to meet patient needs

Documentation (e.g. checklist, algorithm, screenshot) showing use of decision support and standardized treatment protocols to manage workflow in the team to meet patient needs

Wound Care and Hyperbaric Oxygen Therapy Knowledge Base algorithms/ pathways highlighting use of patient-reported outcomes
IA_AHE_3/ Achieving Health Equity
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.
HighParticipation in a Quality clinical data registry (QCDR) and demonstrated performance of activities to promote use of patient-report outcome tools and corresponding collection of PRO data
Participation in QCDR, for use of patient-reported outcome tools, e.g., regular QCDR feedback reports demonstrating use of patient-reported outcome tools and corresponding collection of PRO data, e.g., use of PHQ-2 or PHQ-9 and PROMIS instruments
More topics on MIPS will be published soon. To find out more about how WoundReference can help clinicians perform well in MIPS, contact us


About the Authors

Elaine Horibe Song, MD, PhD, MBA
Dr. Song is a Co-Founder and Chief Executive Officer of WoundReference, Inc., a clinical and reimbursement decision support & telemedicine platform for wound care and hyperbaric clinicians. With a medical, science and business background, Dr. Song previously served as medical director for a regenerative medicine-focused biotech company in California, and for a Joint Commission International-accredited hospital network. Dr. Song also served as a management consultant for Kaiser Permanente, practiced as a plastic surgeon in private practice and academia, and conducted bench and clinical research in wound healing, microsurgery and transplant immunology. Dr. Song holds a position as Affiliate Professor, Division of Plastic Surgery, Federal University of Sao Paulo, and is a volunteer, Committee Chair of the Association for the Advancement of Wound Care. She has authored more than 100 scientific publications, book chapters, software registrations and patents.
Cathy Milne, APRN, MSN, CWOCN-AP
Advanced Practice Wound, Ostomy Continence Nurse at Connecticut Clinical Nursing Associates Connecticut Clinical Nursing Associates American University
An Advanced Certified Hyperbaric Registered Nurse and Certified Wound Specialist with expertise in billing, coding and reimbursement specific to hyperbaric medicine and wound care services. UHMS Accreditation Surveyor and Safety Director. Principal partner of Midwest Hyperbaric LLC, a hyperbaric and wound consultative service. Tiffany received her primary and advanced hyperbaric training through National Baromedical Services in Columbia South Carolina. In 2021, Tiffany received the UHMS Associate Distinguished Service Award. "This award is presented to individual Associate member of the Society whose professional activities and standing are deemed to be exceptional and deserving of the highest recognition we can bestow upon them . . . who have demonstrated devotion and significant time and effort to the administrative, clinical, mechanical, physiological, safety, technical practice, and/or advancement of the hyperbaric community while achieving the highest level of expertise in their respective field. . . demonstrating the professionalism and ethical standards embodied in this recognition and in the UHMS mission.”
With over four decades of healthcare experience, Jeff currently holds the position of Principal Partner at Midwest Hyperbaric LLC and the Co-founder and Chief Clinical Officer of Wound Reference. Jeff has excelled in critical care throughout his career, devoting almost a decade as a Flight Respiratory Therapist/Paramedic for the Spirit of Kansas City Life Flight. In 1993, Jeff transitioned into the field of Hyperbaric Medicine and Wound Care, where he committed 21 years of his career to serving as the Program Director for a 24/7 Level 1 UHMS Accredited facility with Distinction. In this role, he continued to provide patient care while overseeing all administrative, clinical, and daily operations within the Wound Care and Hyperbaric Facility. Jeff is a Registered Respiratory Therapist and a Certified Hyperbaric Technologist (CHT). He has also undergone training as a UHMS Safety Director and a UHMS Facility Accreditation Surveyor. Jeff currently serves as a member of the UHMS Accreditation Council, the UHMS Accreditation Forum Expert Panel, and the UHMS Safety Committee. Additionally, he is an esteemed member of the NFPA 99 Hyperbaric and Hypobaric Facilities Technical Standards Committee. Jeff's dedication to the field has earned him numerous prestigious awards. In 2010, he received the Gurnee Award, which honored his outstanding contributions to undersea and hyperbaric medicine. Three years later, in 2013, he was awarded the Paul C. Baker Award for his commitment to Hyperbaric Oxygen Safety Excellence. Most recently, in 2020, Jeff was honored with "The Associates Distinguished Service Award (UHMSADS)," a recognition reserved for exceptional Associate members of the Society who have demonstrated exceptional professionalism and contributions deserving of the highest accolades.
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