If you are a Merit-Based Incentive Payment System (MIPS) participant, then hopefully you are already familiar with quality measures and improvement activities—the two categories rehab therapists are currently weighted on to determine their MIPS score. But how do they differ and what goes into reporting on each category? This post will examine each category to give you the need-to-know facts for simplified MIPS participation.
A quick overview of the MIPS program.
For rehab therapists, the MIPS program has been around since 2017. Created as a method for CMS to track and reward for effective, outcomes-driven medical care, the program has undergone yearly—sometimes more often—revisions to its present-day form. In its entirety, the traditional MIPS program score is weighted among these four categories:
- Quality Measures
- Improvement Activities
- Promoting Interoperability
- Cost Measures
As mentioned, rehab therapists are currently only scored on the top two categories, with:
- the MIPS Quality Measures category comprising 85% of a participant’s score, and
- the Improvement Activities category accounting for 15% of the score.
But don’t let this weight disparity fool you—maximize one category but flop in the other won’t get you a positive MIPS score. Both are integral to securing that sweet, sweet bonus.
(Of note: If you’re reporting as a group but your practice contains 15 or fewer MIPS-eligible clinicians under the same TIN, then quality measures and improvement activities are re-weighted to 50% each for your final score.)
What are MIPS quality measures?
As the MIPS program’s focus is to promote value-based care, ensuring the delivery of quality care is possibly the most important factor. The Quality Measures category is where MIPS participants must choose six measures from a list provided by the Quality Payment Program (QPP) website that “measures health care processes, outcomes, and patient experiences of care.”
Of the six measures a therapist chooses to be scored on, one of them must be an outcome measure, but in the event an outcome measure is unable to be collected, a participant must instead report an additional high-priority measure. In the case that a MIPS participant has fewer than six measures available, the participant must submit every applicable measure.
MIPS Quality Measures for PTs and OTs
In 2023, the PT and OT specialty measure set contains 25 different measures—18 process measures and seven outcomes measures. Presently, the 18 process measures are:
| 048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older |
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older |
| 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation |
| 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |
| 130 | Documentation of Current Medications in the Medical Record |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan |
| 155 | Falls: Plan of Care |
| 178 | Rheumatoid Arthritis (RA) Functional Status Assessment |
| 181 | Elder Maltreatment Screen and Follow-Up Plan |
| 182 | Functional Outcome Assessment |
| 226 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan |
| 281 | Dementia: Cognitive Assessment |
| 283 | Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management |
| 286 | Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia |
| 288 | Dementia: Education and Support of Caregivers for Patients with Dementia |
| 318 | Falls: Screening for Future Fall Risk |
| 487 | Screening for Social Drivers of Health |
Additionally, PTs and OTs may report seven Focus on Therapeutic Outcomes (FOTO) measures: measures 217–222 and measure 478.
Process Measures vs. Outcome Measures
So, what’s the difference between process measures and outcomes measures? Outcome measures evaluate clinical outcomes as a result of treatment by a MIPS provider, while process measures report on the steps and management methods providers utilize during a patient’s plan of care. Since outcome measures are directly linked to value-based care, CMS has noted they plan to “incrementally remove process measures” in favor of outcome measures.
A quick look at the measures above and you may notice that many of the outcome measures rehab therapists are familiar with—like the LEFS or NDI—are missing. Furthermore, the outcome measures supported by FOTO are proprietary and come with added cost, but this can be remedied with a Qualified Clinical Data Registry (QCDR), like Keet. A QCDR is a CMS-approved agency that can host non-MIPS approved measures—like the LEFS and NDI—as well as streamline efficiencies in your MIPS reporting.
The QPP website also offers a helpful tool that can guide participants toward the measures that best fit their practice.
MIPS Quality Measures for SLPs
In 2023, the SLP specialty measure set contains five different quality measures:
| 130 | Documentation of Current Medications in the Medical Record |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan |
| 181 | Elder Maltreatment Screen and Follow-Up Plan |
| 182 | Functional Outcome Assessment |
| 226 | 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
Quality Measures Scoring
Each quality measure is worth a maximum of 10 points, which brings the full category point cap to 60 points—that is, as long as MIPS-eligible providers reach a certain level of completeness.
For individuals and groups who use QCDR measures, MIPS CQMs, and eCQMs to collect their quality measures, they must report on 70% of all patients—regardless of the payer. And for participants who use Medicare Part B claims to report quality measures, measures must be available on 70% of the Medicare Part B patient pool being treated.
Be prepared: the new data completeness benchmark for MIPS performance year (PY) 2024 will be raised 75%, per CMS’s 2023 final rule.
What are MIPS improvement activities?
Unlike quality measures, improvement activities are a relatively new category with a prophylactic approach. The purpose of this category is to evaluate the ways in which clinicians and groups work to improve their practice as a whole over an extended period of time (e.g., by enhancing care coordination, expanding patient access to care, and improving patient-clinician decision-making).
MIPS Improvement Activities for PTs, OTs, and SLPs
To get started, there are over 100 available activities from which to choose. For a full list, check out the QPP Resource Library. In the meantime, this list can serve as a guide with some common improvement activities WebPT and Keet Members choose to use.
| 003 | Promote Use of Patient-Reported Outcome Tools | High Weight |
| 006 | Regularly Assess Patient Experience of Care and Follow Up on Findings | High Weight |
| 007 | Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. | Medium Weight |
| 008 | Participation in a QCDR, that promotes use of patient engagement tools. | Medium Weight |
| 022 | Improved Practices that Engage Patients Pre-Visit | Medium Weight |
As seen in some of these improvement activities, participation in a QCDR will increase the ease of achieving a maximum score in this category—all while improving patient engagement and clinical success. A win-win!
Improvement Activities Scoring
Improvement activities are classified as either “medium” or “high” depending on demands of the activity, and are awarded 10 or 20 points, respectively. As such, the Improvement Activities category cap is 40 points. To hit this benchmark, individuals and groups may report on any relevant activities—as long as they follow one of these weighting combinations:
- Two high-weighted activities,
- One high-weighted activity and two medium-weighted activities, or
- Four medium-weighted activities.
If you are participating in MIPS as an individual, successful completion of the Improvement Activities category requires you to perform the activity for a consecutive 90-day period at some point during the PY. And if you’re participating as part of a group, at least 50% of the NPIs in the reporting group must complete these activities in order for the full group to receive credit.
Quality measures and improvement activities, a match made in CMS heaven. However, knowing their differences—and how to report on each—is paramount to successful MIPS participation and reimbursement. After all, no one wants to find themselves in the penalty range for their MIPS scores! So give yourself a leg up to compile and communicate patient-reported outcomes with tools like the Keet MIPS QCDR.
Need a little extra guidance or have a burning question? Drop us a line in the comment section below.
