How to Use This Tool
This tool has been created to help you get familiar with the available measures and activities for each performance category under traditional MIPS. It’s for planning purposes only and will not submit anything to CMS. To get the most out of the tool, follow the steps below:
- Explore (Search, browse, or filter) available measures
- Add measures you’re interested in to your list
- Download your list of interested measures for reference
Performance Year
Select your performance year to view across all tabs.
2024 Improvement Activities: Traditional MIPS
15% of final score
This percentage can change due to special statuses, exception applications, Alternative Payment Model (APM) Entity participation, or reweighting of other performance categories.
You must perform between 1 and 4 improvement activities depending on your reporting requirements.
Improvement activities have a continuous 90-day performance period (during the 2024 performance year) unless otherwise stated in the activity description below.
Read more about improvement activities requirements for traditional MIPS.
Additional improvements in access as a result of QIN/QIO TA
As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services or improve care coordination (for example, investment of on-site diabetes educator).Subcategory Name
Expanded Practice Access
Activity Weighting
Medium
Activity ID
IA_EPA_4
Administration of the AHRQ Survey of Patient Safety Culture
Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html). Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.Subcategory Name
Patient Safety And Practice Assessment
Activity Weighting
Medium
Activity ID
IA_PSPA_4
Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data
Use security labeling services available in certified Health Information Technology (IT) for electronic health record (EHR) data to facilitate data segmentation. Certification criteria for security tags may be found in the ONC Health IT Certification Program at 45 CFR 170.315(b)(7) and (b)(8).Subcategory Name
Achieving Health Equity
Activity Weighting
Medium
Activity ID
IA_AHE_10
Advance Care Planning
Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.Subcategory Name
Population Management
Activity Weighting
Medium
Activity ID
IA_PM_21
Anticoagulant Management Improvements
Individual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities:• Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program);• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; or• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.Subcategory Name
Population Management
Activity Weighting
High
Activity ID
IA_PM_2
Application of CDC’s Training for Healthcare Providers on Lyme Disease
Apply the Centers for Disease Control and Prevention’s (CDC) Training for Healthcare Providers on Lyme Disease using clinical decision support (CDS). CDS for Lyme disease should be built directly into the clinician workflow and support decision making for a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include but are not limited to: electronic health record (EHR) based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.Subcategory Name
Patient Safety And Practice Assessment
Activity Weighting
Medium
Activity ID
IA_PSPA_33
Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults
Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.Subcategory Name
Behavioral And Mental Health
Activity Weighting
High
Activity ID
IA_BMH_15
Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women
Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.Subcategory Name
Behavioral And Mental Health
Activity Weighting
High
Activity ID
IA_BMH_14
Care coordination agreements that promote improvements in patient tracking across settings
Establish effective care coordination and active referral management that could include one or more of the following:• Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; • Track patients referred to specialist through the entire process; and/or• Systematically integrate information from referrals into the plan of care.Subcategory Name
Care Coordination
Activity Weighting
Medium
Activity ID
IA_CC_12
Care transition documentation practice improvements
In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.Subcategory Name
Care Coordination
Activity Weighting
Medium
Activity ID
IA_CC_10
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There is no submission requirement for Cost. Cost measures are evaluated automatically through administrative claims data.
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