Note: The 2019 Coronavirus (COVID-19) public health emergency continues to impact clinicians across the United States and territories. However, CMS recognizes that not all practices have been impacted by COVID-19 to the same extent.
For the 2022 performance year, CMS will continue to use our Extreme and Uncontrollable Circumstances policy to allow MIPS eligible clinicians, groups, virtual groups, and APM Entities to submit an application requesting reweighting of one or more MIPS performance categories to 0% due to the current COVID-19 public health emergency. The application will be available in Spring 2022 along with additional resources.
For more information about the impact of COVID-19 on QPP participation, see the Quality Payment Program COVID-19 Response webpage.
Overview
The Improvement Activities performance category assesses your participation in clinical activities that support the improvement of clinical practice, care delivery, and outcomes. With over 100 activities to choose from, you can select from the 2022 MIPS Improvement Activities Inventory to find those that best fit your practice and support the needs of your patients.
For 2022, the improvement activities performance category for traditional MIPS:
- Is worth 15% of your MIPS Final Score.
- Requires you to implement 2 to 4 improvement activities to receive the maximum score of 40 points in this performance category.
- Has a performance period of 90 continuous days for most improvement activities with a few exceptions.
- Requires you to simply attest to activities during the performance year (PY) 2022 submission window (1/3/2023 –3/31/2023). While you do not have to submit any supporting data when you attest to completing an activity, you must keep documentation for 6 years subsequent to submission.
Participation Requirements
Most MIPS eligible clinicians must implement and attest to 2 to 4 improvement activities to receive the maximum score of 40 points in this performance category.
Each improvement activity is worth 10 to 40 points depending on its weight (medium or high) and applicable special status designations.
To achieve the maximum 40 points for the MIPS improvement activities performance category, MIPS eligible clinicians, groups, virtual groups, and APM Entities may use one of the following combinations:
- 4 medium-weighted activities = 40 points
- 2 medium-weighted activities + 1 high-weighted activity = 40 points
- 2 high-weighted activities = 40 points
Reporting/Submission Requirements
To report (or “submit”) an improvement activity, MIPS eligible clinicians, groups, virtual groups, and APM Entities simply attest to having completed it. No supporting data needs to accompany the attestation as part of the submission.
You will need to attest to the completion of your improvement activities or patient-centered medical home participation during the PY 2022 submission period (1/3/2023 – 3/31/2023).
Attention:
While you do not have to submit any supporting documentation when you attest to completing an improvement activity, you must keep documentation of the efforts you or your MIPS group undertook to meet the improvement activity for 6 years subsequent to submission. Documentation guidance for each activity can be found in the 2022 MIPS Data Validation Criteria (ZIP), which contains examples of ways to demonstrate completion of each improvement activity and clarifies the flexibilities clinicians have in implementing the activities.
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.
Scoring
The improvement activities performance category is 15% of your MIPS Final Score in 2022.
This is how the improvement activities performance category is scored:
TIP: Improvement activities can contribute toward no more than 15% of your MIPS Final Score, and you can’t earn more than 40 points in this performance category, regardless of the number of activities you submit.
Scoring Example:
You are a MIPS eligible clinician in a small practice (15 or fewer clinicians) and complete 1 high-weighted improvement activity.
Your improvement activities performance category score is then multiplied by the 15% improvement activities performance category weight. The overall improvement activities performance category score is added to the other performance category scores to determine your MIPS Final Score
Additional Resources
2022 MIPS Improvement Activities User Guide
A guide to help clinicians participating in the improvement activities performance category of the Merit-based Incentive Payment System (MIPS) during the 2022 performance period.
2022 MIPS Data Validation Criteria
Lists the 2022 criteria used to audit and validate data submitted for the Merit-based Incentive Payment System (MIPS) performance categories.
2022 Improvement Activities Quick Start Guide
A guide to help clinicians get started participating in the Improvement Activities performance category of the Merit-based Incentive Payment System (MIPS) during the 2022 performance period.
2022 Improvement Activities Inventory
Provides a complete list of the 2022 improvement activities and includes descriptions for each.