Change to the MIPS 24/7 Practice Improvement Activity

November 20, 2018

Well into the tail-end of the 2018 MIPS performance year, pathologists are now hearing that the frequently-reported Improvement Activity, 24/7 Access (IA_EPA_1), is not meant to be reported by non-patient facing pathologists. 

This contradicts CMS’ response to our inquiry on this topic earlier this fall, in which the Quality Payment Program (QPP) said there were no specific specialty exclusions for reporting the 24/7 activity. 

Muddying the waters are other industry reactions stating that the spirit of the activity can apply to pathologists but would have to be clearly supported in the documentation that clinicians are required to keep on hand for each Improvement Activity to which they’ve attested.   Last year, APS was advised by the QPP that, in addition to proving 24/7 availability and 24/7 access to patient records, documentation to support the 24/7 Improvement Activity would also need to include record of a patient service being provided outside of regular lab hours (ie, weekends or evenings). 

So now what?
Because we have no way of knowing how CMS will score the Improvement Activities category for pathologists reporting the 24/7 activity this year, APS recommends attesting to all activities that apply to your practice to be safe.  Current Improvement Activities can be reviewed at the following link:

Some of the more-frequently reported Activities by our pathology clients include:

• IA_CC_1 Specialists Reports Back to Referring Clinician/Group
• IC_PSPA_2 Participation in MOC Part IV
• IA_PSPA_13 Participation in Joint Commission Evaluation Initiative
• IA_PSPA_14 Participation in Quality Initiatives (ie Bridges to Excellence or other similar

Remember, each activity is weighted as either medium or high and the minimum number you need to report is based on the number of pathologists in your practice:

Groups of more than 15 clinicians

Groups with 15 or fewer clinicians

2 high weighted OR

1 high weighted + 2 medium weighted OR

4 medium weighted

1 high weighted OR

2 medium weighted

We will monitor this topic and provide any relevant updates as they come up.