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IA Measures

Improvement activities breakdown

Care Coordination

Activity Weighting
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IA_CC_1 Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop

Description:

Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_2 Implementation of improvements that contribute to more timely communication of test results

Description:

Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_7 Regular training in care coordination

Description:

Implementation of regular care coordination training.
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_8 Implementation of documentation improvements for practice/process improvements

Description:

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_9 Implementation of practices/processes for developing regular individual care plans

Description:

Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_10 Care transition documentation practice improvements

Description:

In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_11 Care transition standard operational improvements

Description:

Establish standard operations to manage transitions of care that could include one or more of the following:
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_12 Care coordination agreements that promote improvements in patient tracking across settings

Description:

Establish effective care coordination and active referral management that could include one or more of the following:
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_13 Practice Improvements for Bilateral Exchange of Patient Information

Description:

Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following:
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_14 Practice improvements that engage community resources to support patient health goals

Description:

Select and screen for the health-related social needs (HRSN) that are relevant for your patient population using tools that have been tested with underserved populations. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded question/field for the capture of data. After screening, address HRSNs identified through at least one of the following:
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    High

IA_CC_15 PSH Care Coordination

Description:

Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    High

IA_CC_16 Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients

Description:

The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_17 Patient Navigator Program

Description:

Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    High

IA_CC_18 Relationship-Centered Communication

Description:

In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan. The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    Medium

IA_CC_19 Tracking of clinician

Description:

To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period. Reporting the PRC modifiers enables the identification of a clinician
  • Subcategory Name:

    Care Coordination
  • Activity Weighting:

    High