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MIPS 2017: Clinical Practice Improvement Activities (CPIA)

Clinical Practice Improvement Activities (CPIA) is a new category developed for the MIPS program and is intended to assess how much you/your group participate(s) in activities that improve clinical practice. 

How do I report my CPIA category?
The CPIA category allows clinicians to choose those activities most relevant to their practices. CPIA does not require the submission of any additional data.  Instead, it simply requires clinicians to attest to the activities they have participated in for at least 90 consecutive days in 2017 by indicating Yes or No to each activity of the 93 that are available this year. 

The attestations can be reported through the same qualified registry that APS has contracted with this year to submit data for the Quality category.  Please note that APS will assist our clients in completing their attestations and will upload them to the registry on their behalf once completed.

What do I have to document to support the validity of the activities to which I’ve attested?
Because there is no accompanying data submitted with the attestations, CMS has indicated its intent to validate those to which you have attested by conducting audits of the documentation you have in place for the reported activities.  As such, it is imperative that the practice maintain that documentation, to include the appropriate content describing the activity, indicating the duration of time it has been in place, and supporting that the activity was in place for the 90 day time period reported on. 

Please note: for each CPIA, CMS has provided the recommended verbiage that should be included in the documentation of each of your reported activities, as well as what it will look for in validating the activities to which you’ve attested. This can be found at:

https://qpp.cms.gov/about/resource-library (select the MIPS Validation Data link under Documents & Downloads). 

Additional supporting documentation needs will be directed by the specific activity, but would include as applicable:

• Meeting notes and attendance
• Applicable training certificates
• Applicable certifications
• Applicable program participation status
• Scheduling logs (shift and on-call)
• Policies & Procedures/documented processes
• Medical Records/claims data

Which activities could apply to my practice?
This category is determined by the improvement activities you/your practice are currently involved in, or planning to implement for the last quarter of 2017.  While there are over 90 activities from which to choose this year, they will not all be applicable to all specialties or all practices. 

The complete list of activities is available at:  https://qpp.cms.gov/mips/improvement-activities

APS has actively worked with the Quality Payment Program (QPP) for guidance on some of the activities that do appear to be more appropriate for our pathology and radiology clients and that information can be found in the below PDF.

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