Medicare QPP

Physicians Advocacy Institute

Frequently Asked Questions Updated for 2023

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2. How do I submit my information for the improvement activities category? 

  1. Reporting mechanisms, which are available and/or approved differ depending on whether reporting as an individual or group. The following reporting mechanisms can be used for reporting the improvement activities category:
     
    Category Reporting Options
    Improvement Activities Individual, Groups, Virtual Groups and Third-Party Intermediaries (e.g., Qualified Registry, QCDR, CEHRT, CMS-approved survey vendor) Direct; Log-In and Upload; Log-In and Attest (via qpp.cms.gov)
    If you report the improvement activities category using the attestation option, you do not need to submit data on the specific activities to CMS, but you will need to attest “yes” to each activity that you performed, and it is recommended that you retain documentation supporting your attestation for at least 10 years for audit purposes.

    If you report the improvement activities category using a qualified registry, QCDR, EHR technology, or the CMS Web Interface, these intermediaries may have specific data submission requirements for each activity, and these intermediaries will need to certify to CMS that you performed the activities as indicated. It is recommended that you contact the vendor for the reporting mechanism you elect and ask them about their capabilities for reporting the improvement activities category to CMS on your behalf. Again, it is recommended that you retain documentation supporting your attestation for at least 6 years for audit purposes.

    For additional information, please see the PAI’s Improvement Activities Overview.



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