2021 MIPS Improvement Activities

The Improvement Activities (IA) category is a performance category first introduced for the 2017 Merit-based Incentive Payment System (MIPS) performance year by the Centers for Medicare & Medicaid Services (CMS). The IA category is intended to reward clinicians for care focused on coordination, beneficiary engagement, and patient safety. Below are key questions to keep in mind and the list of pathology-specific Improvement Activities for the 2021 MIPS performance year. The CMS reviewed and approved the IAs and suggested documentation included in this document as potentially applicable to pathologists.

The IA category does not have a precedent and is a new category introduced for the MIPS. The IA category is intended to reward clinicians for care focused on coordination, beneficiary engagement, and patient safety.

Improvement Activities account for 15% of a non-patient-facing physician’s MIPS score (for most pathologists the other 85% is Quality Measures. However, if in some instances CMS is able to attribute Cost measures to pathologists in which case Cost is 15% and Quality is 70% of the overall MIPS score; IA will remain at 15%).

Improvement Activities are classified as high-weighted (worth 40 points) and medium-weighted (worth 20 points). The CAP recommends you choose either two medium-weighted or one high-weighted IA.

• Physicians must do the activity for a minimum of 90 continuous days and up to a full year.
• Physicians must keep documentation for 10-years on how they participate in an Improvement Activity.

Many activities pathologists are already doing should qualify for Improvement Activities. According to data collected by the CAP’s 2018 Pathologists Quality Registry, some of the top utilized Improvement Activities by pathologists were:

• Participation in Joint Commission Evaluation Initiative (medium weight = 20 points)
• Implementation of use of specialist reports back to referring clinician or group to close referral loop (medium weight = 20 points)

Please refer to the IA document that the CAP has developed for more guidance on which IA to attest.

Physicians must attest to completing the Improvement Activities by the end of the 2021 MIPS reporting period.

• A simple “yes” is all that is required to attest to completing an improvement activity. However, in the event of an audit, practices will need to ensure they have documentation confirming the completion of the activity.
• Most billing companies cannot provide attestation for Improvement Activities. Therefore, most pathologists will need to attest, such as through a qualified registry, for Improvement Activities. (Groups of 25+ can submit through the CMS web interface).

• For group reporting in 2021, 50% of clinicians in a tax identification number (TIN) entity must perform the same Improvement Activity for the TIN to receive credit.
• Not everyone in the group or TIN has to perform the Improvement Activity at the same time, but they have to perform the same Improvement Activity. Clinicians can perform the activity during any continuous 90-day period during the performance year.
• Clinicians can perform or participate in different initiatives and projects in order to satisfy the same Improvement Activity. The group must retain documentation to show that 50% of the clinicians in the group (TIN) have performed or participated in an initiative or project to support the Improvement Activity or Activities to which the group is attesting.
• Please refer to the case studies the CAP has developed for examples on how a group can satisfy the Improvement Activities requirement in 2021.

Visit the CMS website for more information on Improvement Activities.

Members can login to see 2021 improvement activities we have identified as applicable to pathologists.