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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 2024 to avoid a negative impact on the physician fee payment for the year of 2026. The last continuous 90-day period to perform an improvement activity begins on October 3, 2024.

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". 

Who needs to complete MIPS Improvement Activities?

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

  • Exceptions to these reporting requirements include your MIPS reporting option, special status, clinician type, extreme and uncontrollable circumstances or hardship exception. Detailed information will be available in the 2024 Traditional MIPS Scoring Guide, 2024 APP Scoring Guide and 2024 MIPS Value Pathways Implementation Guide. These will be posted to the QPP Resource Library

For group and Alternative Payment Model (APM) Entity reporting, a group, virtual group, or APM Entity can attest to an activity when at least 50% of the clinicians in the group, virtual group, or APM Entity 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?

Most clinicians must implement and submit 2 to 4 improvement activities to receive the maximum score of 40 points in this performance category. Each improvement activity is classified as either medium-weighted or high-weighted.

  • 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: small practice, rural, health professional shortage area (HPSA), non-patient facing 

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. A MIPS eligible clinician who participates in an APM can receive at least 20 points (out of 40 possible).

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 2024 score, the other categories of the total MIPS score are Quality (30% of the total score), Promoting Interoperability (25%) and Cost (30%). 

Where can I find the MIPS Improvement Activities? 

What’s New with Improvement Activities in 2024?

  • Medicare added 5 new improvement activities:
    • Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services (IA_PM_22)
    • Practice-Wide Quality Improvement in MIPS Value Pathways (IA_MVP)
    • Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines (IA_PM_23)
    • Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women (IA_BMH_14)
    • Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults (IA_BMH_15)
  • Medicare removed 3 improvement activities:
    • Implementation of co-location PCP and MH services (IA_BMH_6)
    • Obtain or Renew an Approved Waiver for Provision of Buprenorphine as MedicationAssisted Treatment [MAT] for Opioid Use Disorder (IA_BMH_13)
    • Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging (IA_PSPA_29)
  • Medicare modified 1 existing improvement activity:
    • Use decision support - ideally platform-agnostic, interoperable clinical decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs (IA_PSPA_16)

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" or enter the numerator and denominator for 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 2024.
  • Proof of participation in an Improvement Activity varies according to the activity and is stated on the  2024 MIPS Data Validation Criteria document. Eligible providers should keep the proof in case of a CMS audit for a period of 6 years as evidence of attestation. The 2024 Data Validation Criteria is available for more details (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 2024 Improvement Activities that can easily be completed with WoundReference. NOTE: to visualize columns on the right, scroll down to the bottom of the table and slide it to the right

WoundReference enabler/ tool ID/Subcategory nameActivity name and descriptionWeightObjetiveSuggested 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. Create and implement a standardized process for providing telehealth services to expand access to care.

Improve health outcomes by expanding patient access to telehealth services that are delivered through standardized processes. 

Include both of the following elements:

1)Standardized processes – Creation of standardized processes for the provision of telehealth services. Examples of documentation include a) description of standardized telehealth processes in an eligible clinician or practice procedures manual; b) workflow diagrams depicting standardized telehealth processes used regularly by an eligible clinician or practice; AND

2)Implementation documentation – Implementation of standardized processes for providing telehealth services. Examples of documentation include a) claims adjudication (may use G-codes to validate); b) electronic health record (EHR); or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient in accordance with standardized processes.

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: PPerformance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.
Improve clinician-to-clinician communication to prevent delayed and/or inappropriate treatment while increasing patient satisfaction and adherence to treatment.

Evidence that relevant records from patient/consultant (internal or external specialist) interactions are sent to the referring eligible clinician.
 Include one of the following elements:
1) Report – Evidence that the consultant always sends a report to the referring eligible clinician; OR
2) Process for capturing referral information – Evidence that the referring eligible clinician has a defined method for capturing reports in the medical record (e.g., a) reports transmitted between electronic health records [EHRs]; b) documents that are electronically scanned and linked to the patient’s EHR; or c) chart documentation of the relevant details of the consultant patient interaction such as notes written into a progress note).  
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 
Evidence of processes for developing and updating individual care plans for at-risk patients and sharing them with beneficiary and/or caregiver. Areas of focus and consideration might include social determinants of health, language and communication preferences, physical or cognitive limitations, as well as desired outcomes of care. Include both of the following elements: 
1) Individual care plans for at-risk patients – Documentation of process for developing individual care plans for clinician-defined at-risk patients (e.g., template care plan, standardized type of note in the health record); AND
2) Use of care plan with beneficiary – Patient medical records demonstrating the documentation of the care plan using a standardized approach.
Example(s): An eligible internal medicine clinician has a population within the practice of frail elderly patients who periodically miss appointments and have not refilled prescriptions. Many are at risk of falls. A plan is developed to identify all of these patients and create a template portion of the electronic health record that asks specific questions regarding caregiver support, ability to travel to appointments and the pharmacy, and the ability to get help whenever needed. The eligible clinician and staff work to help the patient identify solutions to problems.
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).
Documented use of patient safety tools implemented for tracking specific patient safety and practice assessment measures that are meaningful to the eligible clinician or group (e.g., tracking HbA1c would be meaningful to an endocrinologist whereas tracking intraocular pressure would be more meaningful to an ophthalmologist). Include both of the following elements:
1) Evidence of safety tools used – Documentation of the use of patient safety tools that assist in tracking patient safety measures (e.g., practice policy or protocol, workflow diagram, screenshot); AND 
2) Evidence of measures tracked – Documentation of specific patient safety measures tracked via use of tool (e.g., quality measure report, dashboard, screenshot).
  • Surgical risk calculator
  • Document the use of quality measures, evidence-based instruments, and other metrics that contribute to assessing the performance of co-management models, including those focused on patient outcomes, provider satisfaction, patient satisfaction, cost-effectiveness, quality of care provided
  • Write policies around performance benchmarks and goals and plans for how providers and clinical practices will reach and implement these goals.
Wound Care and Hyperbaric Oxygen Therapy  Knowledge Base, algorithms/ pathways, checklists, order sets
IA_PSPA_16/ Patient Safety and Practice Assessment
Use decision support - ideally platform-agnostic, interoperable clinical decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs
HighHelp eligible clinicians align diagnoses and treatment plans with up-to-date, evidence-based standards and guidelines as part of routine care, thus improving the appropriateness of the care they provide and the health outcomes of their patients.

Documented use of decision support and standardized treatment protocols and/or platform-agnostic, interoperable clinical decision support (CDS) tools to manage team workflows to meet patient needs. Include the following element: 

1) Use of decision support and standardized treatment protocols and/or platform-agnostic, interoperable clinical decision support (CDS) tools – Documentation (e.g., checklist, order set, algorithm, screenshot) demonstrating use of decision support and standardized treatment protocols and/or platform-agnostic, interoperable clinical decision support (CDS) tools to manage team workflows to meet patient needs. May include use of artificial intelligence/machine learning.

Example(s)/Information: An eligible clinician group, through peer review, determines that there is significant variability in clinical decision-making for a specific condition. They all agree that standardization of practice is best for patient outcomes. 

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.
HighMake it possible to use Patient Reported Outcomes (PRO) data as part of routine care, thus increasing patient engagement and health outcomes for all populations.
Demonstrated performance of activities to promote use of PRO tools and corresponding collection of PRO data. Include both of the following elements:
1) Promotion of PRO tools – Evidence that eligible clinicians are promoting use of PRO tools with their patients (e.g., documented notes in electronic health record, PRO materials); AND
2) PRO data collection – Feedback reports demonstrating use of PRO tools and corresponding collection of PRO data 

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.
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.
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.”
Cathy Milne, APRN, MSN, CWOCN-AP
Advanced Practice Wound, Ostomy Continence Nurse at Connecticut Clinical Nursing Associates Connecticut Clinical Nursing Associates American University
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