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Improvement Activities

Updated: 06/10/2023|Views: 723

15% of Final Score

Clinicians are rewarded for their participation in clinical activities that support the improvement of clinical practice, care delivery, and patient outcomes. Clinicians can find a variety of activities that best fit their workflow and patient needs. The list of Improvement Activities can be found at 2023 Improvement Activities

There are two kinds of activities: high-weighted and medium-weighted activities. To achieve the maximum score of 40 points and earn the full 15% score, a MIPS eligible clinician may select a combination of activities that add up to 40 points.

  • High-weighted activities: 20 points
  • Medium-weighted activities: 10 points

Improvement activities have a minimum of a continuous 90-day performance period (during calendar year (CY) 2023) unless otherwise stated in the activity description.

Special Status

Clinicians will earn double points for each high or medium weighted activity if they hold a qualifying Special Status of:

  • Small Practice
  • Ambulatory Surgery Center (ASC) -based
  • Health Professional Shortage Area
  • Hospital-based
  • Facility-based
  • Rural
  • Non-patient facing

Clinicians will find any special status assigned to them when checking their MIPS eligibility. Learn more about Special Status.

Supporting Documentation

Read the entire description of the selected Improvement Activities and find ways to prove that set activities were completed. Supporting documentation may include:

  • Screenshots of the EHR and/or Billing (Practice Management)
  • Create policies and procedures
  • Reports
  • Screenshots of a website where the selected activity was completed

Eligible clinicians must report a continuous 90-day performance period unless otherwise stated in the activity description and must keep all supporting documentation for six years as required by the CMS document retention policy. Keeping this documentation in your MIPS 2023 audit binder will give you peace of mind should you be selected for an audit. Remember, you most likely cannot run a report to prove you met a selected Improvement Activity.

Eligible clinicians may submit their improvement activities manually via the Quality Payment Program website.

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