Appendix J2 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form Crosswalk

Improvement Activities Call for Activities Submission Form
CY 2021 Final versus CY 2022 Final
Burden impact: The changes to this self-nomination fact sheet reflect policies in the CY2022
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program and result in an
estimated change of zero hours as submitting a new or modified improvement activity is not a
requirement for a MIPS eligible clinician to participate in the performance category or the MIPS
program.
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Change #1:
Location: Title
Reason for Change:
Added current year and aligned with style guide
CY 2021 Final Rule text:
Call for Activities Submission Form
CY 2022 Final Rule text:
CY 2022 Call for Improvement Activities Submission Form
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Change #2:
Location: Page 1, paragraph 1
Reason for Change:
Alignment with style guide
CY 2021 Final Rule text:
Activities recommended for inclusion or modification
CY 2022 Final Rule text:
Improvement Activities recommended for inclusion or modification
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Change #3:
Location: Page 1, paragraph 1
Reason for Change:
Alignment with style guide, updated to current year, specificity added to include both start and
end date
CY 2021 Final Rule text:
Activities submitted by July 1, 2021CY 2022 Final Rule text:
Improvement activities submitted between February 1 and July 1, 2022
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Change #4:
Location: Page 1, paragraph 1
Reason for Change:
Alignment with style guide and updated for current year implementation timeline
CY 2021 Final Rule text:
Will be considered for inclusion for the Quality Payment program Year 7 (2023)
CY 2022 Final Rule text:
Will be considered for inclusion for the CY 2024 performance period/2026 MIPS payment year

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Change #5:
Location: Page 1, paragraph 1
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
Improvement activities submitted after July 1, 2021, will be considered for inclusion in future
years of the Quality Payment Program.
CY 2022 Final Rule text:
Improvement activities submitted after July 1,2022, will be considered for inclusion in future
years of the Quality Payment program.
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Change #6:
Location: Page 1, paragraph 1
Reason for Change:
Policy change in CY 2022 PFS final rule
CY 2021 Final Rule text:
N/A
CY 2022 Proposed Rule text:
During a public health emergency (PHE), nominations will be accepted outside of the February
1 through July 1 submission period as long as the improvement activity is relevant to the PHE.
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Change #7:
Location: Page 1, paragraph 1
Reason for Change:
Addition clarity, to encourage receipt of improvement activity modification submissions
CY 2021 Final Rule text:
N/A
CY 2022 Final Rule text:
Stakeholders should submit a modification submission if the improvement activity they
submitted or one that refers to a program or policy they manage requires an update.
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Change #8:
Location: Page 1, paragraph 2
Reason for Change:
Alignment with current year and style guide
CY 2021 Final Rule text:
We also refer submitters to the 2021 MIPS Improvement Activities list on the CMS Quality
Payment Program resource library, which lists the complete Inventory of current improvement
activities for the Quality Payment Program Year 5 (2021).
CY 2022 Final Rule text:
We also refer submitters to the 2022 MIPS Improvement Activities list on the CMS Quality
Payment Program resource library, which lists the complete Inventory of current improvement
activities for the CY 2022 performance period/2024 MIPS payment year.
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Change #9:
Location: Page 1, paragraph 3

Reason for Change:
Alignment to reflect change in policy requiring 8 acceptance criteria to be met (some of which
are edits to existing criteria and some are new)
CY 2021 Final Rule text:
MIPS improvement activities considered for selection should meet one or more of the
acceptance criteria. The new list of acceptance criteria for CY 2021 and future years is as
follows:
CY 2022 Final Rule text:
MIPS improvement activities considered for selection must meet all 8 of the required
acceptance criteria below:
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Change #10:
Location: Page 1, paragraph 3
Reason for Change:
Addition for clarity to reflect policies in CY
2022 PFS final rule, moved order
CY 2021 Final Rule text:
Feasible to implement, recognizing importance in minimizing burden, especially for small
practices, practices in rural areas, or in areas designated as geographic HPSAs by HRSA;
CY 2022 Final Rule text:
Feasible to implement, recognizing importance in minimizing burden, including to the extent
possible, for small practices, practices in rural areas, or practices in areas designated as
geographic Health Professional Shortage Areas (HPSAs) by the Health Resources and
Services Administration (HRSA);
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Change #11:
Location: Page 1, paragraph 3
Reason for Change:
Addition for clarity to reflect policies in CY 2022 PFS final rule
CY 2021 Final Rule text:
Includes activities which can be linked to existing and related MIPS quality and cost measures,
as applicable and feasible.
CY 2022 Final Rule text:
Can be linked to existing and related MIPS quality, Promoting Interoperability, and cost measures
as applicable and feasible.
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Change #12:
Location: Page 1, paragraph 3
Reason for Change:
Addition of new criteria to reflect policies in CY 2022 PFS final rule
CY 2021 Final Rule text:
N/A
CY 2022 Final Rule text:
•Does not duplicate other improvement activities in the Inventory; * and
•Should drive improvements that go beyond purely common clinical practices. *
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Change #13:
Location: Page 1, paragraph 4

Reason for Change:
Updates to year and language to refer to year of the Call for Improvement Activities
CY 2021 Final Rule text:
*New submission criterion for submissions made in CY 2021
CY 2022 Proposed Rule text:
*New submission criterion for CY 2022 Call for Improvement Activities
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Change #14:
Location: Page 2, paragraph 3
Reason for Change:
New policy to include optional 6 acceptance criteria
CY 2021 Final Rule text:
N/A
CY 2022 Proposed Rule text:
MIPS improvement activities considered for selection can also meet one or more of the optional
acceptance criteria below. Meeting one or more of the optional criteria may increase a
submission’s chances of being added to the Inventory:
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Change #15:
Location: Page 2, paragraph 3
Reason for Change:
Updated order/location to reflect which criteria are now optional and ensure text is as written in
CY 2022 PFS final rule
CY 2021 Final Rule text:
• Importance of an activity that could lead to improvement in practice to reduce health care
disparities;
• Aligned with patient-centered medical homes;
• Focus on meaningful actions from the person and family’s point of view;
• Supports the patient’s family or personal caregiver;
• Include a public health emergency as determined by the Secretary; or
CY 2022 Final Rule text:
• Alignment with patient-centered medical homes;
• Support for the patient’s family or personal caregiver;
• Responds to a PHE as determined by the Secretary;
• Addresses improvements in practice to reduce health care disparities;
• Focus on meaningful actions from the person and family’s point of view; and
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Change #16:
Location: Page 2, paragraph 4, table
Reason for Change:
Alignment with style guide
CY 2021 Final Rule text:
Eligible Clinician
CY 2022 Final Rule text:
MIPS eligible clinician
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Change #17:

Location: Page 3, paragraph 1, table
Reason for Change:
Edits for clarity, remove the term validation
CY 2021 Final Rule text:
Validation of Activity: Supporting Documentation
CY 2022 Final Rule text:
Rationale and Supporting Documentation
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Change #18:
Location: Page 3, paragraph 1, table
Reason for Change:
Addition of language tied to the current required acceptance criteria
CY 2021 Final Rule text:
Provide supporting validation documentation
CY 2022 Final Rule text:
Describe how this activity would meet the acceptance criteria listed above. Provide supporting
documentation.
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Change #19:
Location: Page 3, paragraph 1, table
Reason for Change:
Addition of language for clarity
CY 2021 Final Rule text:
Include data or primary sources that could be used to substantiate performance
CY 2022 Final Rule text:
Include data or primary sources that a MIPS eligible clinician could use to validate performance