If you’re an individual or group planning to participate in the new Improvement Activities (IA) category of MIPS, you should be aware that you must begin engaging in your chosen activities by no later than Oct. 2 in order to complete the 90 days of participation requirement in 2017.
While non-patient facing (NPF) and small physician groups face a lower reporting burden than regular participants, the IA category still counts for 15 percent of your overall MIPS score, regardless of the number of activities you’re required to complete.
As a refresher, activities are weighted as either high or medium depending on their administrative burden. A patient-facing group must complete some combination of the following: two high-weighted, four medium-weighted, or one high and two medium-weighted. Meanwhile, NPF physicians and groups of 15 or fewer providers must only complete either one high-weighted or two medium-weighted activities to earn the full 40 points available for the category.
If you’re unsure whether or not your group qualifies for special status under MIPS, you can check by entering your NPI at qpp.cms.gov.
CMS has approved a list of 93 activities for 2017. If you’re unsure which activities would work best for your group, take time to review the whole list to check whether you’re already engaging in an improvement activity. Vachette has also assisted numerous clients through this process and is available to make recommendations on activities that would best suit your practice.
While you won’t be required to report anything to CMS during the 90 days you’re completing the activity, you will be expected to sign an attestation form stating you completed the activity when CMS opens the attestation portal sometime in early 2018. This form will simply require you to complete a survey with questions pertaining to your chosen activity. You’re not required to submit documentation proving you completed your activities, however, you should still be documenting completion of the activity in the rare event CMS elects to audit your MIPS performance.
One activity that we’ve recommended for several pathology clients is a high-weighted activity titled “24/7 Access to the MIPS Eligible Clinician With Access to Patient Records.” Since the vast majority of pathologists already have someone from their group available 24/7, this is a relatively simple choice.
To document this activity, groups should be maintaining a shift log showing who from the group was available on what days during the extended evening and weekend hours. Additionally, patient-care activities performed during these hours should also be documented. This could include items such as a blood smear interpretation signed out of your EMR, or a surgical pathology report that was signed electronically during normal business hours a day or two after the “after hours” event, but includes documentation of an after-hours frozen section evaluation that was part of the case.
Regardless of which activities you choose, now is the time to get moving if you haven’t already. If your group is just looking to avoid the 2019 MIPS penalty, completing just a single improvement activity this year will help you achieve that goal. Don’t wait until it’s too late to start!