At long last: The documentation you need for Improvement Activity audits

Improvement Activities is the brand new addition to the suite of measures in the Merit-Based Incentive Payment System (MIPS). Unlike the Quality and Advancing Care Information categories, which are based heavily on previous Centers for Medicare & Medicaid Services (CMS) programs (PQRS and Meaningful Use, respectively,) Improvement Activities do not have a predecessor.

On top of that, the descriptions of each Improvement Activity from CMS are relatively short. For reporting, all you need to do is attest to having performed the activity for at least 90 days. But that has left everyone wondering…what evidence or proof do I need to have in case of an audit?

At long last, CMS has released recommended documentation for each Improvement Activity. Below you can find documentation recommendations for five of the most popular Improvement Activities among our clients. You can access the full list of documentation recommendations here.

When you are choosing Improvement Activities, you should first review the full list to see if there are any you already do. While below activities are commonly selected, they may not be a fit for your organization:

Measure title (linked to full description) Why eligible clinicians are choosing this activity Suggested documentation (inclusive of dates during the selected continuous 90-day or year-long reporting period)
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record Some clinicians and groups have this functionality built into their EHRs. This measure also qualifies for 10 bonus points in the Advancing Care Information category, since it counts toward the bonus measure, Report improvement activities using CEHRT.
  1. Patient Record from EHR – A patient record from a certified EHR with date and timestamp indicating services provided outside of normal business hours for that clinician; or
  2. Patient Encounter/Medical Record/Claim – Patient encounter/medical record claims indicating patient was seen or services provided outside of normal business hours for that clinician including use of alternative visits; or
  3. Same or Next Day Patient Encounter/Medical Record/Claim – Patient encounter/medical record claims indicating patient was seen same-day or next-day to a consistent clinician for urgent or transitional care
Collection and use of patient experience and satisfaction data on access Many practices and groups already perform patient experience surveys, which either already includes a question on patient access, or the group can easily add one.
  1. Access to Care Patient Experience and Satisfaction Data – Patient experience and satisfaction data on access to care; and
  2. Improvement plan – Access to care improvement plan
Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination Groups using Able Health QCDR have easy access to regular feedback reports for quality improvement.
  1. Participation in QCDR demonstrating promotion of standard practices, tools and processes for quality improvement, e.g., regular feedback reports provided by QCDR that demonstrate the use of QCDR data to promote use of standard practices, tools, and processes for quality improvement, including, e.g., preventative screenings
Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes This is a relatively easy Improvement Activity to implement for many practices and groups.
  1. Clinical and Administrative Leadership Role Descriptions – Documentation of clinical and administrative leadership role descriptions include responsibility for practice improvement change (e.g. position description); or;
  2. Time for Leadership in Improvement Activities – Documentation of allocated time for clinical and administrative leadership participating in improvement efforts, e.g. regular team meeting agendas and post meeting summary; or;
  3. Population Health, Quality, and Health Experience Incorporated into Performance Reviews – Documentation of population health, quality and health experience metrics incorporated into regular practice performance reviews, e.g., reports, agendas, analytics, meeting notes
Tobacco use Since MIPS 226 Tobacco Screening and Cessation Intervention is a common measure for many eligible clinicians and groups, this improvement activity leverages existing work on that measure.
  1. Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice of tobacco screening for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence

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Further reading:
2018 MIPS Composite Score Overview: How you will be scored in year 2 of the Merit-Based Incentive Payment System
6 ways to improve MIPS quality performance with the data you already have

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