This week, CMS released information regarding suggested documentation for the Improvement Activities category of MIPS. The table includes examples of suggested documentation for each of the 94 improvement activities, but does not provide any specifications for completing individual improvement activities. It is important to remember that the only required data submission for this category is attestation to the activities. For full credit in the category, practices with 15 or fewer Medicare providers only need to submit one high-weighted or two medium-weighted activities. Practices of 16 or more providers are required to submit two high-weighted, four medium-weighted, or a combination of one high-weighted and two medium-weighted activities. For example, use of a Qualified Clinical Data Registry, such as IRIS, or expanded practice hours count as high-weighted activities. Full information about this category is available on our MACRA Center web page.
In addition, CMS released a fact sheet on 2017 MIPS Data Validation and Auditing. The fact sheet notes that MIPS participants may receive audit requests and must respond within 10 business days. Practices should keep documentation for up to 10 years, in accordance with the False Claims Act, and CMS may request records or data related to MIPS for up to 6 years. For the 2017 performance year based on the final rule, CMS will only audit data from the Quality category, but it is recommended that practices retain records for the Advancing Care Information and Improvement Activities categories as well. ASCRS also has developed a fact sheet, which you may view here.
If you need additional information, please contact Allison Madson, manager of regulatory affairs, at firstname.lastname@example.org or 703-591-2220.