From the Washington Office

Clinical Practice Improvement Activities: The New Reporting Requirement


As was summarized last month, Centers for Medicare and Medicaid Services (CMS) released the final rule pertaining to the Medicare Access and CHIP Reauthorization Act (MACRA) on October 14, 2016. In the ensuing weeks, Division of Advocacy and Health Policy staff had the opportunity to read and further analyze the rule. In general, the initial favorable impression held up under more careful scrutiny. Based on the provisions in the final rule, we continue to make adjustments and modifications to the resources available to Fellows to assist them to prepare for 2017 on the website found at By the time this column is printed/released, I anticipate that the video series found on the website will have been updated and expanded upon.

Because change is unsettling, one of the most frequent topics of conversation and question concerning MACRA is the new reporting requirement known as Improvement Activities. Previously, in the proposed rule, this component was known as the Clinical Practice Improvement Activities. In the final rule, the nomenclature was shortened to Improvement Activities.

Dr. Patrick V. Bailey

Dr. Patrick V. Bailey

The Improvement Activities will comprise 15% of the MIPS Composite Performance Score. Surgeons may select from a list of 93 activities. Each activity is assigned a point value of either 20 or 10 points. In order to achieve full credit, surgeons will need to acquire a total of 40 points and, accordingly, report on two, three or four activities. For those surgeons in small or rural practices, full credit is achieved with only 20 points, thus either one or two activities. These final rule requirements represent a 50% reduction from those initially proposed.

The reporting mechanism specified by CMS for 2017 is simple attestation. That attestation may be accomplished via any traditional reporting mechanism other than by claims. Accordingly, the use of CMS approved “traditional” registries (registry reporting option) or qualified clinical data registries, such as the ACS’ Surgeon Specific Registry (SSR), will be valid modes by which one may report. Discussions are underway to determine how best to incorporate the Improvement Activities into the SSR. Alternatively, CMS plans to make available a portal on its website where providers will be able to attest to their having satisfied the Improvement Activity requirement.

In reviewing the list of 93 activities, examples of such that likely would or could be applicable to surgeons include:

• Use of a QCDR (qualified clinical data registry) to generate regular performance feedback (20 points)

• Participation in a QCDR, clinical data registries, or other registries run by other government agencies or private entities such as a hospital or medical or surgical society (10 points)

• Provision of episodic care management, including management across transitions and referrals that could include routine and timely follow-up to hospitalizations and ED visits and/or managing care intensively through new diagnoses, injuries and exacerbations of illness (10 points)

• Provision of specialist reports back to referring providers to close the referral loop (10 points)

• Timely communication of test results defined as timely identification of abnormal test results with timely follow-up (10 points)

• Participation in a QCDR, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (10 points)

• Bilateral exchange of necessary patient information to guide patient care that could include participation in a health information exchange or use of structured referral notes (10 points)

• Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities (10 points)

• Use of evidence-based decision aids to support shared decision-making (10 points)

• Participation in Maintenance of Certification Part IV (10 points)

• Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice (10 points)

• Consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II opioid prescription that lasts for longer than 3 days (20 points)

• Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator (10 points)

• Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare (20 points)

Based upon the list above (and others not included), and because the requirement specified for reporting the Improvement Activities is simple attestation, I am confident that all surgeons will be able to meet the requirement with minimal effort and achieve full credit for this component of the MIPS Composite Performance score. In these last weeks of 2016, I would encourage all Fellows to visit the ACS QPP website at to map out their overall strategy for success with the new Medicare physician payment system that will become effective beginning in January of 2017.

Until next month ….

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