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MIPS for Infusion Practices: The "W" Questions in Reporting on Improvement Activities


Infusion centers are not necessarily exempt from MIPS, and many clinicians working in infusion centers may find that they are required to submit for MIPS in order to avoid penalties. Practices and providers must first check their eligibility to participate as Eligible Clinicians (ECs). See our previous blog on how to check your status.

The Improvement Activity (IA) performance category is required for clinicians to submit data on clinical practice improvement activities. There are over 100 Improvement Activities and they fall into these sub-categories as defined by QPP: Expanded Practice Access, Population Management, Care Coordination, Patient Safety and Practice Assessment, Achieving Health Equity, Behavioral and Mental Health, Emergency Response and Preparedness, and Beneficiary Engagement.

Practices or clinicians need to submit a combination of activities to get full credit for the category. At least 50 percent of the Eligible Clinicians (if reporting as a group) need to participate in each activity for a 90-day continuous period of the Performance Year (PY). Some practices will receive a special status and have their points doubled if they fall in one of the categories, such as being located in a rural area, or in a health professional shortage area (HPSA). As an example, when reporting on a high-weighted activity, typically worth 20 points, those practices with special status will automatically receive 40 points for completion. These special statuses are included as part of the QPP Participation Status look up tool.

Clinicians reporting will attest to performing an activity or activities for a 90-day reporting period during the performance year, which makes the last day to start a new activity - October 3, 2021.

The larger questions arise at:

  • What measures do you consider for reporting?Are there any that the data will be more easily supported within your EHR?And are there some measures that are not applicable in your infusion center?
  • What method do you use to report?How is that method supported – and can you ensure you will have the proper data to back up your submission?
  • What time frame do you consider for reporting your 90-days? Data available in the next few weeks (rather than the end of the year) could provide a better representation of your infusion center’s performance.

These questions can easily be discussed with our MIPS team of experts, deciding what makes sense for your infusion practice and the Eligible Clinicians.

Look for more information on the Improvement Activities category and what reporting means to your reimbursements from CMS in future articles.

The Quality Reporting Engagement Group has partnered with practices to help them receive over $70 million in incentive money for the quality of their care, regardless of their specialty or the EHR they use.  To start a conversation or ask questions of one of their experts, contact