Practice Management Toolbox

Quality reporting of improvement activities in 2020


2020 has begun and therefore so has a new year of quality reporting requirements. Quality reporting under the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) may seem like a burden, but it doesn’t need to be. You can likely get credit for the things you are already doing in your practice with little to no augmentation needed.

Dr. Brijen J. Shah

First, there are a few pieces of information to keep in mind when tracking your data and preparing your staff for their 2020 strategy.

1. Group Participation – For 2020 there is an increase in the MIPS participation threshold for those participating as part of a group. At least 50% of the MIPS eligible clinicians in the reporting group must participate in the same continuous 90-day period to receive credit for a quality improvement activity. That’s a significant increase from 2019 when only one (1) MIPS eligible clinician in a group was required to participate. Connect with your staff now to make sure your group meets the new 50% participation requirement.

2. Improvement Activities for Group Participation – Improvement Activities that are approved for credit by CMS are given a weight based on their requirements. Approved activities are weighted as either medium or high, and this impacts how many activities a practitioner must report on. In 2020, CMS increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice for the Improvement Activities category along with other changes such as modifying the definition of rural area to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy using the most recent file available, updating the improvement activities and removing some criteria for Patient-Centered Medical Home designation. Work with your staff now to make sure at least 50% of the MIPS-eligible clinicians in your group are participating in the same Improvement Activities.

3. Quantity of Improvement Activities Required – CMS requires most individuals or groups report on any of the following options during any continuous 90-day period (or as specified in the activity description) in the same performance year, provided that all participating clinicians are reporting on the same activities:
a. 2 high-weighted activities, or
b. 1 high-weighted and 2 medium-weighted activities, or
c. 4 medium-weighted activities

Be sure to pay attention to the weight of the activity you (if you’re reporting as an individual) or your group is reporting so you don’t have any surprises at the end of the reporting period.

There are a variety of options for activities you can report on and some may be a lower lift than you expect.

Does your practice treat Medicaid patients? If so, do you know their average wait time for an initial visit? If that number is 10 days or less, you can report on this activity. If you aren’t quite hitting this benchmark, then consider implementing a scheduling protocol for this population of your patients in the new year.


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