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Quality & Practice

Improvement Activities


Within the Quality Payment Program, there are 2 paths providers can choose and use to report quality data:

 

Improvement Activities (IA) is a new category in the MIPS program and was created to promote ongoing improvement and innovation. IA's account for 15% of your total MIPS score.

MIPS Improvement Activities Score.

In order to comply with 2017 reporting requirements, eligible clinicians must attest to completing 4 activities for at least 90 days each. IA allow clinicians to choose the activities that are most meaningful to their practice to demonstrate performance. 

 

To help our members with their IA attestation, AAPM&R has created a MIPS Improvement Activity Guide to help them explore the activities that may be most applicable to the specialty.

All of your MIPS reporting can be completed using the Spine Quality Outcomes Database.

NEW! Use AAPM&R Practice Improvement Projects (PIPs) to Qualify for MIPS

The Academy recently learned that engagement in its Practice Improvement Projects (PIPs) can qualify as an Improvement Activity (IA) under the 2017 Merit-Based Incentive Payment System (MIPS). By participating in MOC Part IV and engaging in an AAPM&R PIP for at least 90 consecutive days, you can attest to IA_PSPA_2: Participation in MOC Part IV. Attesting to this single, medium-weighted activity will allow you to avoid a 4% Medicare payment penalty in 2019, and, if paired with the submission of other MIPS data, may also help you to earn a small incentive payment!

AAPM&R offers 4 Practice Improvement Projects (PIPs):

Participants of each PIP are required to systematically review and document their activities, which CMS requires a monthly documentation for Quality Improvement Activities, to assess performance in practice by reviewing outcomes, addressing areas of improvement, and evaluating the results. 

Bonus: AAPM&R PIPs are FREE to Academy members, offer 20 CME, and help meet your Part IV American Board of Physical Medicine and Rehabilitation (ABPMR) Maintenance of Certification® requirement!

A few stipulations:

  1. You must be participating in Maintenance of Certification. Documentation may be required, should you be audited.
  2. You must perform the PIP consistently across your practice for a continuous period of at least 90 days during the MIPS measurement period (1/1/17 through 12/31/17). If you have already engaged in a PIP for a minimum of 90 consecutive days, or started your participation on or before October 2, 2017 and continue for 90 days, you can claim this IA.  
  3. You or your practice must attest to completion of this activity in 2017 via the CMS Web-Based Attestation Portal website—AAPM&R cannot do this for you. This portal will launch in early 2018 and clinicians will have until March 31, 2018 to submit 2017 attestations. Although you will not be required to submit any supporting documentation to CMS at the time of attestation, you are encouraged to maintain documentation related to your completion of the PIP for at least 6 years in the event that CMS audits you to validate your performance. 

Additional information about the Improvement Activities category of MIPS, and other activities that might qualify, can be found at: https://qpp.cms.gov/mips/improvement-activities.  More detailed documentation requirements can be found in the MIPS Validation Criteria document in the QPP Resource Library at https://qpp.cms.gov/about/resource-library. Questions? Feel free to contact AAPM&R at (847) 737-6000.