Activities

The following table lists activities that are most applicable to eyecare practices. To see a complete list of improvement activities, go to https://qpp.cms.gov/mips/improvement-activities.

Weight	Subcategory	Activity Name	Activity Description	Validation	Suggested Documentation
High	Population Management	IA_PM_3 RHC, IHS or FQHC quality improvement activities	Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.	Evidence of quality improvement activity participation as part of RHC, Indian Health Service (HIS), or FQHC participation. By vulnerable populations/patients, CMS is referring to racial and ethnic minorities, refugees, those who are elderly, financially disadvantaged, or without health insurance, and those who have a disability or medical condition which are associated with disparities in outcomes across populations.	Name of RHC, IHS or FQHC – Identified name of RHC, IHS, or FQHC in which the eligible clinician participates in ongoing engagement activities; AND Continuous quality improvement activities - Documented continuous quality improvement activities aimed at services provided to RHC, IHS, or FQHC patients. To the extent possible, these quality improvement activities should contribute to more formal quality reporting, and should include receiving quality data back for broader quality and benchmarking improvement (e.g., data reports or dashboards tied to quality improvement projects).
High	Beneficiary Engagement	IA_BE_6 Regularly Assess Patient Experience of Care and Follow Up on Findings	Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS-eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.	Evidence that patient experience and satisfaction data are collected, and that follow-up occurs through an improvement plan.	Report of patient experience and satisfaction – Report including collected data on patient experience and satisfaction (e.g., survey results). Report may include description of effort to implement patient surveys in multiple languages based on the needs of the patient population. The eligible clinician or practice may use a third-party administrator; AND/OR Follow-up on patient experience and satisfaction – Documentation that the eligible clinician’s practice has implemented changes based on the results of the patient experience and satisfaction data gathered and analyzed (e.g., specific improvements made to practices/processes in response to survey results); AND/OR Patient experience and satisfaction improvement plan – Documentation of a patient experience and satisfaction improvement plan.
High	Achieving Health Equity	IA_AHE_1 Enhance Engagement of Medicaid and Other Underserved Populations	To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat data (i.e., data measuring the time between clinician identifying a need for an appointment and the patient having a scheduled appointment) to identify patterns by which care or engagement with Medicaid patients or other groups of underserved patients has not achieved standard practice guidelines; and with this information, create, implement, and monitor an approach for improvement. This approach may include screening for patient barriers to treatment, especially transportation barriers, and providing resources to improve engagement (e.g., state Medicaid non-emergency medical transportation benefit).	Evidence of eligible clinicians tracking and improving timeliness of care delivered to patients from underserved populations, including those with Medicaid, through analysis and intervention.	Analysis of time-to-treat data – Report documenting analysis of trends and inequities in time-to-treat data, disaggregated by beneficiary type (to compare those with and without Medicaid benefits) and by other patient demographics such as race/ethnicity, disability status, sexual orientation, sex, gender identity, or geography. Report should include possible explanations for the trends and inequities identified; AND Implementation Plan and Results – Documentation of plans for activities to address inadequacies in time-to-treat performance, and the outcomes of those activities. Activities may address barriers facing patients (e.g., lack of access to affordable transportation) or barriers presented by the eligible clinician (e.g., appointment availability does not align with needs of those who lack sick leave).
High	Achieving Health Equity	IA-AHE_11 Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients	Create and implement a plan to improve care for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients by understanding and addressing health disparities for this population. The plan may include an analysis of sexual orientation and gender identity (SO/GI) data to identify disparities in care for LGBTQ+ patients. Actions to implement this activity may also include identifying focused goals for addressing disparities in care, collecting and using patients’ pronouns and chosen names, training clinicians and staff on SO/GI terminology (including as supported by certified health IT and the Office of the National Coordinator for Health Information Technology US Core Data for Interoperability [USCDI]), identifying risk factors or behaviors specific to LGBTQ+ individuals, communicating SO/GI data security and privacy practices with patients, and/or utilizing anatomical inventories when documenting patient health histories.
High	Expanded Practice Access	IA_EPA_6 Create and Implement a Language Access Plan	Create and implement a language access plan to address communication barriers for individuals with limited English proficiency. The language access plan must align with standards for communication and language assistance defined in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (https://thinkculturalhealth.hhs.gov/clas).
High	Emergency Response & Preparedness	IA_ERP_2 Participation in a 60-day or greater effort to support domestic or international humanitarian needs.	Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.	Evidence of participation in domestic or international humanitarian volunteer work for at least a continuous 60 day duration.	Details and confirmation of participation – Documentation of participation in domestic or international humanitarian volunteer work for at least a continuous 60 day duration including registration and active participation (e.g., identification of location of volunteer work, timeframe, and confirmation from humanitarian organization)
Medium	Achieving Health Equity	IA_AHE_7 Comprehensive Eye Exams.	To receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by any one or more of the following: Providing literature Facilitating a conversation about this topic using resources such as the “Think About Your Eyes” campaign Referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology’s EyeCare America and the American Optometric Association’s VISION USA Promoting access to vision rehabilitation services as appropriate for individuals with chronic vision impairment. This activity is intended for the following: Nonophthalmologists / optometrists who refer patients to an ophthalmologist/optometrist Ophthalmologists/optometrists caring for underserved patients at no cost Any clinician providing literature and/or resources on this topic This activity must be targeted at underserved and/or high-risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams or vision rehabilitation services.	Evidence that eligible clinicians help underserved and/or high-risk populations understand the importance of their eye health and provide support to access comprehensive eye exams.	Proof of eligible clinician/group type – Evidence that the attesting eligible clinicians are either: a providing literature and/or resources on the topic of comprehensive eye exam importance; AND Promotion of comprehensive eye exam – Documentation that literature and/or conversation about the importance of comprehensive eye exams were provided to targeted underserved and/or high-risk populations (e.g., visit note made in medical record; copy of literature provided); AND 3) Referrals to no-cost eye exams – Documentation of patient referrals made to resources providing no-cost eye exams (e.g., American Academy of Ophthalmology's EyeCare America, American Optometric Association's VISION USA) for targeted underserved and/or high-risk populations
Medium	Achieving Health Equity	IA_AHE_10 Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data	Use security labeling services available in certified Health Information Technology (IT) for electronic health record (EHR) data to facilitate data segmentation. Certification criteria for security tags may be found in the ONC Health IT Certification Program at 45 CFR 170.315(b)(7) and (b)(8).
Medium	Expanded Practice Access	IA_EPA_2 Use of telehealth services that expand practice access	Documented use of telehealth services and participation in data analysis assessing provision of quality care with those services	Evidence of the creation and implementation of standardized processes for providing telehealth services. Telehealth services may include care provided over the phone, online, etc., and are not limited to the Medicare-reimbursed telehealth service criteria.	Standardized processes – Creation of standardized processes for the provision of telehealth services. Examples of documentation include a) description of standardized telehealth processes in an eligible clinician or practice procedures manual; b) workflow diagrams depicting standardized telehealth processes used regularly by an eligible clinician or practice; AND Implementation documentation – Implementation of standardized processes for providing telehealth services. Examples of documentation include a) claims adjudication (may use G-codes to validate); b) electronic health record (EHR); or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient in accordance with standardized processes.
Medium	Expanded Practice Access	IA_EPA_3 Collection and use of patient experience and satisfaction data on access	Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.	Evidence of documented improvement plan for access to care and quality based on collected and stratified patient experience and satisfaction data. The goals for improvement can be defined broadly or within certain population strata. CMS examples of stratification may include patient demographics such as race/ethnicity, disability status, sexual orientation, sex, gender identity, or geography. (It is acknowledged that some stratification data may not be available).	Patient experience and satisfaction data on access to care – Data collected through a patient experience survey for a population defined by the eligible clinician. For example, eligible clinicians could give the survey to all patients seen within a defined study period. Data can be prepared in any useful format, or as they were collected; AND Improvement plan – Documentation of an improvement plan, which should include specific activities, goals, and outcomes for addressing access to care. For example, an eligible clinician may observe that non-English-speaking patients were not confident in their interactions with eligible clinicians because of language barriers. A possible plan could include using translators, remote translation services, or language training. The improvement plan would include details regarding who would be trained with timelines for completion.
Medium	Emergency Response and Preparedness	IA_ERP_6 COVID-19 Vaccine Achievement for Practice Staff	Demonstrate that the MIPS eligible clinician’s practice has maintained or achieved a rate of 100% of office staff staying up to date with COVID vaccines according to the Centers for Disease Control and Prevention. Please note that those who are determined to have a medical contraindication specified by CDC recommendations are excluded from this activity.
Medium	Population Management	IA_PM_11 Regular review practices in place on targeted patient population needs	Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.	Evidence of participation in identification and reviews of targeted patient population needs.	Targeted patient population identification – Documentation of method/s for identification and ongoing monitoring of a targeted patient population (e.g., policy or protocol), including stratification of patient data by demographic characteristics and, as needed, health-related social needs to appropriately identify differences among populations and assess drivers of gaps and inequities, as well as identifying interventions appropriate for the needs the targeted population; AND Review of targeted population’s unique characteristics and needs – Report that compiles information on the unique characteristics of the targeted patient population, including inequities in relevant outcomes; ways to tailor clinical treatments to meet needs and reduce inequities (e.g., clinicians treating Black men, who have a higher incidence of prostate cancer, may choose to evaluate that population for consistency of screening); and lists of community resources that can further support patients with these needs outside of the clinical setting; AND Implementation Report – Report with action plan detailing steps the practice has taken to address the results of its targeted population identification and needs assessment.
Medium	Care Coordination	IA_CC_1 Implementation of use of specialist reports back to referring clinician or group to close referral loop	Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.	Evidence that relevant records from patient/consultant (internal or external specialist) interactions are sent to the referring eligible clinician.	Report – Evidence that the consultant always sends a report to the referring eligible clinician; AND Process for capturing referral information – Evidence that the referring eligible clinician has a defined method for capturing reports in the medical record (e.g., a) reports transmitted between electronic health records [EHRs]; b) documents that are electronically scanned and linked to the patient’s EHR; or c) chart documentation of the relevant details of the consultant patient interaction such as notes written into a progress note).
Medium	Care Coordination	IA_CC_12 Care coordination agreements that promote improvements in patient tracking across settings	Establish effective care coordination and active referral management that could include one or more of the following: Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS-eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/or Systematically integrate information from referrals into the plan of care.	Evidence of care coordination and referral management	Care coordination agreements – Documentation of care coordination agreements that establish flow of information and provide patients with information to set consistent expectations; OR Tracking of patient referrals to specialists – Medical record or electronic health record documentation demonstrating tracking of patients referred to specialists through the entire process; OR Referral information integrated into the plan of care – Samples of specialist referral information systematically integrated into the plan of care.
Medium	Care Coordination	IA_CC_13 Practice improvements for bilateral exchange of patient information (PI-bonus eligible)	Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following: Participate in a Health Information Exchange if available; and/or Use structured referral notes.	Evidence of exchange of patient information (between care team and patient) to guide patient care.	Participation in a Health Information Exchange (HIE) – Confirmation of participation in a health information exchange (e.g., email confirmation, screenshots demonstrating active engagement with HIE); OR Utilization of OpenNotes – Clinical documentation from a medical record available in a patient portal.
Medium	Beneficiary Engagement	IA_BE_1 Use of certified EHR to capture patient reported outcomes (PI-bonus eligible)	To improve patient access, perform activities beyond routine care that enable capture of patient reported outcomes (for example, related to functional status, symptoms and symptom burden, health behaviors, or patient experience) or patient activation measures (that is, measures of patient involvement in their care) through use of certified electronic health record technology, and record these outcomes data for clinician review.	Evidence of patient reported data and/or outcomes in the certified EHR	Patient reported outcomes/self-management – Documentation demonstrating use of one or more measures that assess patients’ involvement in their care or their understanding, confidence, and ability to care for oneself. The eligible clinician should incorporate the results of the assessment into the patient’s overall plan of care, as deemed most appropriate for their population. As necessary or helpful, also include patient’s data in the certified EHR.
Medium	Beneficiary Engagement	IA_BE_15 Engagement of patients, family and caregivers in developing a plan of care (PI-bonus eligible)	Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.	Evidence of inclusion of patients, family, and caregivers in developing plan of care with prioritization of goals for action, as documented in the electronic health record (EHR). The eligible clinician will identify the patient population that will participate in this activity.	Patient, family, and caregiver involvement – Report or screenshot from the EHR showing the plan of care and prioritized goals for action with notes from engagement of patients and/or their families and caregivers. May use another electronic platform to systematically capture patient preferences/value through a validated patient experience measure instrument.
Medium	Patient Safety & Practice Assessment	IA_PSPA_12 Participation in private payer CPIA	Participation in designated private payer clinical practice improvement activities.	Evidence of participation in private payer clinical practice improvement activities.	Confirmation of participation – Documents showing participation in private payer clinical practice improvement activities (e.g., quality measure documentation or feedback reports, practice workflow redesign tools developed for or with the payer as part of practice improvement)
Medium	Patient Safety and Practice Assessment	IA_PSPA_19 Implementation of formal quality improvement methods, practice changes or other practice improvement processes	Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: Participation in multisource feedback; Train all staff in quality improvement methods; Integrate practice change/quality improvement into staff duties; Engage all staff in identifying and testing practices changes; Designate regular team meetings to review data and plan improvement cycles; Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data; Participation in Bridges to Excellence; Participation in American Board of Medical Specialties (ABMS) Multispecialty Portfolio Program.	Evidence of the implementation of a formal plan for QI and creation of a culture in which staff actively participates in one or more applicable QI activities. This activity allows MIPS clinicians to build the foundations for other activities they pursue in the future.	Adopt formal quality improvement plan and create culture of improvement – Documentation of adoption of a formal model for QI and creation of a culture in which staff actively participate in QI activities. Formal QI models are used by eligible clinicians to develop systems, tools, and interventional strategies to improve processes of care for their patient population; AND Staff participation – Documentation of staff participation in one or more of the 6 key areas for improvement*: a) training; b) integration into staff duties; c) identifying and testing practice changes; d) regular team meetings to review data and plan improvement cycles; e) share practice and panel level quality of care; f) patient experience and utilization data with staff; or g) share practice level quality of care, patient experience and utilization data with patients and families.
Medium	Emergency Response & Preparedness	IA_ERP_1 Participation on Disaster Medical Assistance Team, registered for 6 months.	Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.	Evidence of participation in Disaster Medical Assistance Team or Community Emergency Responder Team for at least 6 months as a volunteer.	Details and confirmation of participation – Documentation of participation in Disaster Medical Assistance or Community Emergency Responder Teams for at least 6 months including registration and active participation (e.g., attendance at training, on-site participation).
Medium	Behavioral and Mental Health	IA_BMH_2 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 226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.	Demonstration of regular engagement in integrated prevention and treatment interventions including tobacco use screening and cessation interventions for patients with a diagnosis of behavioral or mental health disorders with risk factors for tobacco dependence.	Identification of patients with behavioral or mental health conditions and tobacco dependence risk factors – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry, or other system demonstrating that the eligible clinician tracks patients with conditions of behavioral health or mental health with risk factors for tobacco dependence; AND Evidence of screening – Report from EHR, QCDR, clinical registry, or documentation from medical charts showing regular practice of tobacco screening for patients with conditions of behavioral or mental health with risk factors for tobacco dependence; AND Evidence of cessation interventions – Report from EHR, QCDR, clinical registry, or documentation from medical charts showing regular practice of tobacco cessation interventions for patients with behavioral or mental health disorders with risk factors for tobacco dependence.