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The Improvement Activities (IA) category accounts for 15% of the Merit-Based Incentive Payment System (MIPS) Composite Score in 2021. This category provides an opportunity for cardiothoracic surgeons to be recognized for engaging in activities that contribute to higher quality health care, but that are not capturable through traditional quality measures. MIPS participants may select from more than 100 possible IAs. Eligible activities focus on beneficiary engagement, care coordination, behavioral and mental health, achieving health equity, population management, practice assessment, expanded practice access, and more.

To receive the maximum score for this category, clinicians must perform an IA for a minimum of 90 days during the performance period. In general, clinicians must attest to performing either:

  • Two 20-point, high-weighted activities;
  • Four 10-point, medium-weighted activities; or
  • Another combination of high- and medium-weighted activities equaling 40 points.

Small (15 or fewer clinicians and solo practitioners) and rural practices are only required to attest to one high-weighted or two medium-weighted activities to receive the full performance score in this category.

Starting in 2020, CMS modified the requirements for satisfying this category at the group level. Groups can only attest to an improvement activity if at least 50% of the clinicians in the group complete the same activity during any continuous 90-day period. Previously, only one clinician in the group needed to complete the activity for the group to receive credit.

STS has identified improvement activities that may be relevant to cardiothoracic surgery practices, although you are encouraged to review the entire inventory, which changes slightly each year, and decide which activities are most appropriate for your specific practice.

Also note that for 2021, as in 2020, clinicians may attest to a high weighted activity titled, "COVID-19 Clinical Data Reporting with or without Clinical Trial," which recognizes clinicians who participate in a COVID-19 clinical trial and have the information entered into a data platform for that study, as well as clinicians who participate in the care of COVID-19 patient data to a clinical data registry for purposes of future study.

Last updated: 6/15/2021