2023 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 2023 MIPS performance year. These Improvement Activities have been successfully reported to CMS through the Pathologists Quality Registry.

The IA category is intended to reward clinicians for care focused on coordination, beneficiary engagement, and patient safety. Activities include emergency preparedness, addressing health equity, and introducing formal methods of quality improvement.

The weight of the Improvement Activities category varies depending on practice size. For large pathology practices (16 clinicians or more), the IA category is 15% of the final MIPS score. The other 85% is the Quality category. For small pathology practices (15 or fewer clinicians), the IA category is 50% of the final MIPS score. The other 50% is the Quality category.

For non-patient-facing clinicians, 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.
• At least 50% of the physicians in a practice must perform the same IA. Clinicians can work on different projects or initiatives within an Improvement Activity but must contribute to the same overall IA
  • Example: Pathology Practice, LLC has three pathologists. Pathologist A completes his OPPE activity between February and March 2023. Pathologist B chooses a different OPPE metric and completes hers between March and May 2023. This satisfies IA_PSPA_13 for this practice
• 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. Some of the top Improvement Activities utilized by pathologists include:

• 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)

The CAP has developed a new IA specifically geared towards pathologists: IA_ERP_5, Implementation of a Laboratory Preparedness Plan, which supports development, implementation, and updating of plans to support continued or expanded patient care during public health emergencies including COVID.

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 2023 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.

• For group reporting in 2023, 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 2023.

Visit the CMS website for more information on Improvement Activities.

Members can login to see 2023 improvement activities we have identified as applicable to pathologists.