Improvement Activities (IA) – One of the MIPS performance categories that refer to all sorts of activities register quality healthcare services. And, its data submission in MIPS 2021 reporting period is particularly useful after the peak corona time.

So, if you are willing for successful MIPS 2021 data submission, this article will give you a brief guide about the relevant additional AI reporting requirements. We are sure you must be familiar with the basic reporting criteria, so we won’t be repeating that.

However, let’s go through the detailed requirements to help you excel in the Improvement Activities for MIPS 2021 reporting.

Number of activities to attest

For MIPS 2021 reporting eligible parties, individuals, groups, virtual groups, and APM entities that are MIPS eligible can perform activities in the following combinations

  1. 4 medium-level activities = 40 points
  2. 2 medium-level and 1 high-level activity = 40 points
  3. 2 high-level activities = 40 points

For Special Status Designations

Parties who are eligible for the special status designations can perform activities in the following combinations

  1. 2 medium-level activities = 40 points
  2. 1 high-level activity = 40 points

Participation Requirements

For Patient-Centered Medical Homes

To qualify for a patient-centered medical home designation, the practice needs to meet one of the following for at least a continuous 90-day period.

  1. Must have received certification from a nationally recognized accreditation organization.
  2. Be participating in a Medicaid medical home or medical home model.
  3. Be a specialty practice recognized through a specialty program organized by a nationally acclaimed specialty organization.
  4. Must have received accreditation from other certifying bodies, namely those who have approved of several medical organizations and meet national guidelines.

For an APM or MIPS APM

If a clinician is MIPS eligible and is up for QPP MIPS 2021 reporting, and they are participating in the Alternative Payment Model (APM) or MIPS APM, they automatically score 20 points out of the total 40.

And if the clinician is a MIPS APM participant, they will receive full credit a.k.a 40 points, if they are reporting the APP (APM Performance Pathway).

You can get more information about this from the APP webpage. A better approach is to go for MIPS consultants. They can help you simplify all MIPS reporting methods by analyzing what method is best for your medical practice.

Report Submission Options

There are a few different ways you can submit your data for the MIPS evaluation.

  • You as an individual party, be it you as a singular practitioner, as a group, a virtual group, etc. can manually attest and submit your report here at the official QPP MIPS website. However, as mentioned above, professional assistance is better than doing everything on your own. They can help you make all the right decisions.
  • You or a third party as a MIPS Qualified Registry can sign into the QPP portal to submit MIPS 2021 reporting data and upload the file with your attested activities.
  • You can also let the third party completely handle it. They will directly upload your data through computer-to-computer interaction on the QPP submission API.

Things to Remember

Few points to keep in mind while submitting your data are,

  • If a third-party vendor as a Qualified Registry is used for report submission, ensure they are registered and support your performance category and desired activities.
  • Most activities can be performed and reported in consecutive years, but there are some exceptions to that.

For example, the activity Administration of the AHRQ Survey of Patient Safety Culture (IA_PSPA_4) can only be implemented once every four years.

  • No supporting data is needed for attestation. However, you must keep the report that you or your MIPS consultants submitted for six consecutive years, as it shows evidence that you performed the improvement activity.

Documentation Guidelines

Documentation guidelines are different for each activity. But they can consist of things like,

  1. Screenshots or digital captures of information that support your attestations.
  2. Improvement plans or outlines that support the strategies or processes used for the intent of the activity.
  3. Electronic health records should be retained regarding the specific improvement activity as evidence.


The improvement activities category is scored in the following way.

Improvement activities score = x 100

This score is multiplied by the 15% improvements category weight. The number obtained is then added together with the scores of other categories to get your MIPS composite or final score.


Getting a good MIPS score is crucial for clinicians as it directly affects how much of a positive payment adjustment they will be getting. It can help them expand their practices, take on more staff, and grow their services as medical practitioners.

The minimum points for avoiding the penalty in MIPS 2021 reporting are 60, and it can only be achieved if the clinicians get good scores in all of the main categories, including the improvements activities. So, pay attention to this efficiently.