Scoring

The default scoring methodology for IA is that a medium activity is 10 points and a high activity is 20 points.  A total of 40 points is needed to receive full credit for this category.  However CMS has made an exception for many practices: "For small practices, rural practices, or practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS eligible clinicians, we will reduce the requirement to only one high-weighted or two medium weighted activities."  Specifically, these practices will receive double credit (20 points for medium activities and 40 points for high activities).  A small practice has been defined as a practice with fewer than 15 providers.


Reporting

Note that while the measures below support the Improvement Activities, the measures themselves are not reported.  The reporting is a Yes/No attestation stating that the practice is using the measure(s) actively to improve care.  The actual attestation needs to be done by the provider via a portal.


The IA section of MIPS allows for many options to reach your maximum score.  Most of these are not supported by the Clinigence application.  You may select IA activities which are not supported by Clinigence or you may select a combination of Clinigence supported activities and other activities. 


Supported Activities

Clinigence can provide measures to support the below improvement activities in the practice.


ACTIVITY NAME
ACTIVITY DESCRIPTION
ACTIVITY ID
SUBCATEGORY NAME
ACTIVITY WEIGHTING
Points
Depression screening
Depression screening and follow-up plan:  Regular engagement of MIPS eligible clinicians or  groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.
IA_BMH_4
Behavioral and Mental Health
Medium
10
Diabetes screening
Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.
IA_BMH_1
Behavioral and Mental Health
Medium
10
MDD prevention and treatment interventions
Major depressive disorder: Regular engagement of MIPS eligible clinicians or  groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.
IA_BMH_5
Behavioral and Mental Health
Medium
10
* Measurement and improvement at the practice and panel level
Measure and improve quality at the practice and panel level that could include one or more of the following:  Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.

* no specific measure, covered by 2018 MIPS program measures
IA_PSPA_18
Patient Safety & Practice Assessment
Medium
10
Tobacco use
Tobacco use: Regular engagement of MIPS eligible clinicians or  groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.
IA_BMH_2
Behavioral and Mental Health
Medium
10
Unhealthy alcohol use
Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or  groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.

*Clinigence has created a custom measure for tracking progress on this IA which employs the alcohol screening and counseling approach that is specified in NQF #2152 with the addition of criteria pertaining to the occurrence of diagnoses of behavioral or mental health conditions within 24 months.

In general these are at the types of diagnoses that qualify:
•Behavioral disorders due to psychoactive substance use (other than alcohol)
•Schizophrenia, schizotypal and delusional disorders
•Mood (affective) disorders
•Neurotic, stress-related and somatoform disorders (includes anxiety disorders)
•A subset of sleep and eating disorders
•Personality disorders and a subset of impulse disorders
•Attention deficit disorder
IA_BMH_3
Behavioral and Mental Health
Medium
10


* Note that Activity ID IA_PSPA_18 can be achieved by using the Clinigence CQM's in the Quality section and the Clinigence application to "Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level."