
# CMS Suspends Eight Improvement Activities for the Merit-based Incentive Payment System (MIPS) for 2025


The Centers for Medicare & Medicaid Services (CMS) is suspending eight improvement activities for the 
2025 performance year (PY) in accordance with the Merit-based Incentive Payment System (MIPS) 
Improvement Activities Suspension Policy finalized in the CY2021 Physician Fee Schedule (PFS) final 
rule (86 FR 65465). We intend to propose removing these improvement activities in future rulemaking.
***

**Table 1: MIPS Improvement Activities Suspended for PY 2025**
<table>
  <tr>
    <th style="width: 150px;">Activity ID</th>
    <th style="width: 700px;">Activity Name</th>
  </tr>
  <tr>
    <td>IA_AHE_5</td>
    <td>MIPS Eligible Clinician Leadership in Clinical Trials or CBPR</td>
  </tr>
  <tr>
    <td>IA_AHE_8</td>
    <td>Create and Implement an Anti-Racism Plan</td>
  </tr>
  <tr>
    <td>IA_AHE_9</td>
    <td>Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols</td>
  </tr>
  <tr>
    <td>IA_AHE_11</td>
    <td>Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients</td>
  </tr>
  <tr>
    <td>IA_AHE_12</td>
    <td>Practice Improvements that Engage Community Resources to Address Drivers of Health</td>
  </tr>
  <tr>
    <td>IA_PM_6</td>
    <td>Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities</td>
  </tr>
  <tr>
    <td>IA_ERP_3</td>
    <td>COVID-19 Clinical Data Reporting with or without Clinical Trial</td>
  </tr>
  <tr>
    <td>IA_PM_26</td>
    <td>Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B</td>
  </tr>
</table>

***
Clinicians should select other improvement activities to complete. However, if any of the suspended 
improvement activities have already been completed or were in the process of being completed, clinicians
will still be able to attest to completing them and receive credit. Please review the <a href="https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/3158/Links-to-2025-MIPS-Measure-Specs-Activity-Inventory-and-Supporting-
Documentation.pdf" target="_blank" rel="noopener noreferrer">
  2025 Improvement Activities Inventory</a> for available improvement 
activities.

Visit the [QPP website](https://qpp.cms.gov/) for more information.

**Please Note:** CMS is in the process of updating all related resources (i.e. guides, factsheets, webpages, 
etc.), including the Explore Measures and Activities tool, to indicate these improvement activities have 
been suspended for PY 2025

CMS Suspends Eight Improvement Activities for the Merit-based Incentive  Payment System (MIPS) for 2025

**CMS Reopens 2024 MIPS Hardship Exception Applications Due to IV Fluid Shortages and extends the 2024 MIPS 
Submission Deadline to April 14th**

**3/28/2025**

Beginning March 31, physicians will have a 15-day window to apply for a hardship exception related to last fall’s IV fluid 
shortages to avoid potential penalties under the Merit-Based Incentive Payment System (MIPS). The data submission 
deadline for physicians not impacted by the shortages has also been extended to April 14.

Following advocacy from the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS) is 
reopening applications for the MIPS Extreme and Uncontrollable Circumstances (EUC) exception for performance year 
2024, which affects 2026 Medicare payment adjustments.

Physicians can submit EUC applications between March 31 and April 14 at 7 p.m. CT. The application allows them to request 
reweighting of all four MIPS performance categories—quality, cost, promoting interoperability, and improvement activities—
to avoid penalties of up to 9%, if their performance was impacted by the shortage.

To apply, physicians should log into the QPP website and follow the instructions.

CMS 2024 Submission Deadline Extension

This year, take steps to secure a positive payment 
adjustment under the MIPS Program.

**Are you prepared for the Merit-Based Incentive 
Payment System (MIPS) in 2024?**

Navigating this Medicare performance-based incentive 
program can be daunting, whether your practice is a 
seasoned participant or a newcomer. With upcoming 
reductions in Medicare reimbursement, participation 
might be more beneficial than ever. If your practice 
serves Medicare patients and you're uncertain about 
how to optimize MIPS for your practice, or even where to 
begin, keep reading for some valuable tips.

<a href="https://ga-marketing-website.s3.us-east-1.amazonaws.com/news/RBMA+Article.pdf" target="_blank">Click 
Here To Read More</a>


Maximize Your 2024 MIPS Performance

**NEW YORK, NY | February 19, 2024** - Guidance 
Analytics™, a leader in automated Merit-based Incentive 
Payment System (MIPS) reporting, for radiology 
practices partners with ImagineSoftware™, the leading 
provider of revenue cycle management technology. 
Through the partnership, ImagineSoftware will integrate 
Guidance Analytics’ MIPS reporting technology as a 
solution for customers to accurately report upon and 
comply with Medicare’s Quality Payment Program.

At the cornerstone of this partnership, Guidance 
Analytics and ImagineSoftware offer a comprehensive 
approach to automating the radiology revenue cycle and 
MIPS reporting workflows. Leveraging both systems, 
radiology practices and billing organizations streamline 
workflows, increase accuracy, and maintain compliance, 
all producing significant financial impact.

Guidance Analytics’ Managing Member, Brian Gale, MD, 
MBA commented, “We are excited to enter this 
partnership with ImagineSoftware and look forward to 
helping their customers streamline their MIPS reporting 
process, maximize their MIPS payment adjustments, and 
help them provide quality outcomes to their patients.”

“Our partnership with Guidance Analytics is evidence of 
our commitment to driving efficiency and accuracy for 
our clients, through cutting-edge technology and a 
strong partner network that match our vision,” states 
Tim White, ImagineSoftware’s Vice President of Channel 
Partner Sales. “Between ever-changing volumes, 
legislative changes, and labor shortages, it is critical for 
providers and practice administrators to automate 
workflows for efficient revenue cycle operations, and 
compliance-maintaining workflows. Together, 
ImagineSoftware and Guidance Analytics are enhancing 
radiology practice operations, allowing our clients to 
focus their time on the quality of the patient experience.”

### About  Guidance Analytics

**Guidance Analytics**, the leading provider of 
automated Artificial Intelligence (AI) solutions for 
radiology quality management. Our platform includes a 
state-of-the art AI solution that rapidly evaluates and 
scores MIPS measures and a dynamic dashboard, 
DataLUX™, that gives our practices real-time MIPS 
performance feedback and provides workflow to 
manage and improve their individual measure scores. 
Coupled with our consulting sessions we help our 
radiology practices maximize their MIPS payment 
adjustments and **Break Through the MIPS Reporting 
Barrier**. 

### About ImagineSoftware
**ImagineSoftware™**
 is the leading provider of revenue cycle management 
technology, including medical billing automation 
software and Artificial Intelligence-driven platform. 
Offering powerful technology solutions for medical 
billing offices, physician practices, and hospitals for over 
20 years, ImagineSoftware™ currently serves more than 
75,000 physicians across 43 specialties. 
ImagineSoftware™ solutions improve financial efficiency, 
build provider reputation, and ultimately improve the 
patient experience.



Guidance Analytics and ImagineSoftware team up to offer Automated Radiology MIPS Reporting Solution — Guidance Analytics

Radiologists generally have only two MIPS categories 
available to them. Quality, which comprises 85% of their 
overall MIPS score and Improvement Activities for the 
remaining 15%. Unless they are classified as a small 
practice of fifteen or fewer radiologists where the 
reweighting becomes 50% for each the two categories. 
This puts radiologists in position of relying heavily on 
their Quality score to contribute to their overall MIPS 
score.

 

Most practices are only submitting traditional QPP 
measures to CMS. Unfortunately, there are fewer and 
fewer QPP measures that are relevant to radiologists. 
Many of these measures have been eliminated and 
benchmarks are becoming more and more stringent, 
yielding fewer points per measure each year.

 

**How can radiologists expand available measures?**

 

The best way for radiologists to add measures is to take 
advantage of the ACR Qualified Clinical Data Registry 
(QCDR). The ACR offers twenty-two additional measures 
designed specifically for radiologists. The ACR's 
benchmarked measures can earn ten points. More 
measures are expected to be benchmarked this year.



**Guidance Analytics is the best way for radiologists to 
take advantage of the ACR QCDR Measures**


 

Our AI platform, Velocity MIPS Reporter, automatically 
analyzes your data and determines MIPS scores for both 
the ACR QCDR and traditional MIPS QPP measures. Our 
consultants host regular MACRA optimization sessions 
during the year to help your practice stay on track to 
optimize providers’ performance and maximize your 
Medicare payment adjustment.

You want a QCDR for MIPS

Prior to 2022, CMS has never penalized more than 3% of 
all providers. The rules have recently changed. CMS is 
now required to penalize everyone with below-average 
scores. In 2022, CMS estimates that approximately 33% 
of all providers will pay into the penalty pool. In 2023, 
the number increases to 38%.

Average scores will get tougher to achieve in 2023. The 
first five years of MACRA were structured to be easy. 
Many of those elements have gone away. Bonus points 
on Quality were eliminated in 2022 and the Exceptional 
Bonus Pool has been eliminated in 2023. Benchmarks 
continue to get tougher, and penalty thresholds are 
higher.

The good news is that the penalty pool is used to fund 
the payment pool. Radiologists who score above the 
penalty threshold can earn up to a 9% positive payment 
adjustment. In 2023, there is real money on the table for 
higher performing radiologists. However, most practices 
will need assistance to achieve higher MIPS scores.

Velocity MIPS Reporter uses AI to automatically analyze 
your data and determine MIPS scores. Our consultants 
host regular MACRA optimization sessions during the 
year to help your practice stay on track to optimize 
providers’ performance and maximize your Medicare 
payment adjustments.

Higher 2023 MIPS Penalties is Good News

The Centers for Medicare and Medicaid Services (CMS) 
released the Final Rule changes to the Quality Payment 
Program for 2023 on November 1, 2022. The rule 
provides policy updates to the traditional Merit-based 
Incentive Payment System (MIPS) program and the new 
MIPS Values Pathway (MVPs) framework.

**2023 Performance Threshold**

The proposed rule will continue to use the 75 point 
performance penalty threshold for the 2023 
performance year.

**Exceptional Bonus Pool**

There will no longer be an additional performance 
threshold for exceptional performance in 2023. The 
2022 performance year is the last year clinicians can 
earn an exceptional performance bonus.

**MIPS Performance Category Weights**

There will be no changes to the MIPS performance 
category weights in 2023. For most radiologists, Quality 
will continue to be weighted at 85% and Improvement 
Activities will be weighted at 15%.

For small practices, CMS will continue to automatically 
reweight Improvement Activities performance 
categories. Quality and Improvement Activities will each 
be weighted at 50%.

*non-patient facing radiologists

**Improvement Activities Updates**

There are no major changes to the MIPS Improvement 
Activities (IA) category other than updates to the IA 
inventory. CMS is adding four new activities, modifying 
five current activities, and removing five existing 
improvement activities from the IA inventory

**2023 Quality Measure Benchmarks:**

The following changes in Quality measure benchmarks 
go into effect beginning with the 2023 performance 
period:

Measures with a benchmark - The 3-point floor is 
removed for measures that can be scored against a 
benchmark. These measures will receive 1-10 points.

Measures without a benchmark - The 3-point floor is 
removed for measures without a benchmark (except 
small practices). These measures will receive 0 points 
(small practices will continue to earn 3 points).

Measures that don’t meet case minimum requirements 
(20 cases) - The 3-point floor is removed (except small 
practices). These measures will earn 0 points (small 
practices will continue to earn 3 points).

**MIPS Value Pathways (MVPs)**

CMS will make MVPs available for reporting gradually, 
beginning with the 2023 performance year. However, 
there will not be any radiology MVPs in 2023.

The CMS 2023 Quality Payment Program Final Rule is Here - Learn What Changes are Ahead for MIPS Reporting

**Guidance Analytics recently participated in an 
education session about MIPS, the CMS Final Rule for 
2023 and strategies for radiology practices.**

<a href="https://ga-marketing-website.s3.us-east-
1.amazonaws.com/news/EducationalPresentation112022.
pdf" target="_blank">Educational Presentation (Nov 
2022)</a>



Presentation: MIPS Overview and Strategies for 2023

The Centers for Medicare and Medicaid Services (CMS) 
released proposed changes to the Quality Payment 
Program for 2023 on July 7, 2022. A 60-day comment 
period will be open until September 6, 2022. The 
proposal could undergo additional changes before the 
final regulation is issued in November.

**2023 Performance Threshold**

The proposed rule would continue to use the 75 point 
performance penalty threshold for the 2023 
performance year.

 

**Exceptional Bonus Pool**

There will no longer be an additional performance 
threshold for exceptional performance in 2023. The 
2022 performance year is the last year clinicians can 
earn an exceptional performance bonus.

**MIPS Performance Category Weights**

CMS is not proposing any changes to the MIPS 
performance category weights in 2023. For most 
radiologists, Quality will continue to be weighted at 85% 
and Improvement Activities will be weighted at 15%.

For small practices, CMS will continue to automatically 
reweight Improvement Activities performance 
categories. Quality and Improvement Activities will each 
be weighted at 50%.

**2023 Quality Measure Benchmarks:**

* The following changes in Quality measure benchmarks 
go into effect beginning with the 2023 performance 
period:
* 
* Measures with a benchmark - The 3-point floor is 
removed for measures that can be scored against a 
benchmark. These measures will receive 1-10 points.
* 
* Measures without a benchmark - The 3-point floor is 
removed for measures without a benchmark (except 
small practices). These measures will receive 0 points 
(small practices will continue to earn 3 points).
* 
* Measures that don’t meet case minimum requirements 
(20 cases) - The 3-point floor is removed (except small 
practices). These measures will earn 0 points (small 
practices will continue to earn 3 points).
* 
* New measures- New measures are subject to a floor of 
7 points in the first year and 5 points in the second year.
*

 

**MIPS Value Pathways (MVPs)**

CMS will make MVPs available for reporting gradually, 
beginning with the 2023 performance year. However, 
there will not be any radiology MVPs in 2023.

The 2023 Quality Payment Program Proposed Rule is Here - Learn What Changes are Ahead for MIPS Reporting

CMS continues to offer an Extreme and Uncontrollable 
Circumstances Exception in 2022. In prior years, they 
provided an automatic exemption to all providers who 
didn't report. In 2022 the exemption is no longer 
automatic. Providers must demonstrate that they've 
been affected by extreme and uncontrollable 
circumstances that impact their MIPS performance 
categories.

We have been advising practices to consider that 2022 
will be the best year in the history of MIPS to earn real 
money. With the exceptional bonus pool set to expire for 
2023, and the expectation that 40-50% of all providers 
will be penalized, the pool of money available for positive 
payment adjustments is more significant. You should 
consider claiming your fair share.

Velocity MIPS Reporter uses AI to automatically analyze 
your data and score MIPS and ACR Quality measures. 
Our consultants will provide your practice with MACRA 
optimization sessions throughout the year. We will help 
your practice stay on track to optimize providers’ 
performance and maximize your Medicare payment 
adjustments.

Let Guidance Analytics:
* **Analyze your radiology practice's MIPS 
performance**
* 
* **Provide a financial projection of your 2022 payment 
adjustment**

Can I take an automatic MIPS exemption in 2022?

Prior to 2022, CMS has **never penalized more than 
3%** of all providers.  The rules have changed this year. 
CMS is required to penalize everyone with below-
average scores. This means that nearly **50% of all 
providers will pay** into the penalty pool.  

Average scores will get tougher to achieve in 2022. The 
first five years of MACRA were structured to be easy. 
Many of those elements go away this year. Bonus points 
on Quality have been eliminated, benchmarks get 
tougher, and penalty threshold are higher.

 

The good news is that the penalty pool is used to fund 
the payment pool. Radiologists who score above the 
penalty threshold can earn up to a 9% positive payment 
adjustment and benefit from the bonus pool. In 2022, 
there is real money on the table for higher performing 
radiologists. However, most practices will need 
assistance to achieve higher MIPS scores.

 

Velocity MIPS Reporter uses AI to automatically analyze 
your data and determine MIPS scores. Our consultants 
host regular MACRA optimization sessions during the 
year to help your practice stay on track to optimize 
providers’ performance and maximize your Medicare 
payment adjustments.

Are Higher 2022 MIPS Penalties Good News?

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  Your browser does not support the video tag.
</video>


A review and update for the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System 
(MIPS). Published by Radiology Business.

VIDEO: Where we are with MIPS and MACRA in radiology

**NEW YORK, NY, February 23, 2022 – Guidance 
Analytics, provider of automated Artificial Intelligence 
(AI) solutions for radiology quality management 
announced today that it has signed an Agreement with 
West County Radiological Group, a leading radiology 
practice in Saint Louis County, MO for the full suite of 
Guidance Analytics’ solutions:**

**Velocity MIPS Reporter™**

Radiology practices must review hundreds of thousands 
of radiology reports in order to comply with Medicare's 
Quality Payment Program (QPP), which has significant 
financial impact. Manual review can be inaccurate, slow, 
and expensive. Guidance Analytics offers an automated 
AI solution, Velocity MIPS Reporter™ to evaluate 
radiology reports rapidly and accurately to determine 
the Merit-Based Incentive Payment System (MIPS) 
scores. The solution provides interim feedback, enabling 
providers to improve their performance during the year.

**Velocity Follow-up Manager™**

The process to schedule recommended follow-up 
imaging exams is fraught with challenges. As many as 
35% of these exams are never scheduled. Velocity 
Follow-up Manager™, is a solution that closes the loop 
on these missed procedures, reclaims lost revenue and 
mitigates the potential patient liability from missed 
appointments.

“Guidance Analytics is our first partner chosen for its AI 
capabilities. With the changes in MIPS quality measures, 
it was imperative to find a partner who could take the 
burden off our coders, maximize our MIPS scores, and 
ensure we are providing quality care for our patients,” 
stated Carol Hamilton, Practice Administrator at West 
County Radiological Group.

Guidance Analytics’ Managing Member, Brian Gale, MD, 
MBA commented, “We are excited to partner with West 
County Radiological Group and look forward to helping 
them maximize their MIPS payment adjustments as well 
as help them provide quality outcomes to their patients.”

**About West County Radiological Group**

West County Radiological Group (WCRG) is the largest 
private radiology practice in the St. Louis area. Since 
1969 they have been serving the Saint Louis area and 
other regions in Missouri through their partnership with 
the Mercy Health System. Their practice areas include 
radiology, nuclear medicine, interventional radiology, 
stroke, and radiation oncology. WCRG also has a fully 
staffed medical physics group providing diagnostic and 
radiation therapy services for a variety of facilities 
throughout Missouri. For more information, please visit 
https://westcountyradiology.com/.






West County Radiological Group Signs Agreement with Guidance Analytics for Velocity MIPS Reporter™ and Velocity Follow-up Manager™

**Guidance Analytics, LLC today announced it will be 
showcasing their two solutions at the Radiological 
Society of North America (RSNA) 2021 Annual Meeting, 
Velocity MIPS Reporter and Velocity Follow-up Manager. 
Using advanced Artificial Intelligence (AI) algorithms and 
deep industry experience, these solutions streamline 
workflows for radiology organizations.**

Velocity MIPS Reporter automatically processes 
radiology reports to score and submit Merit-Based 
Incentive Payment System (MIPS) Quality measures. 
This AI-powered solution has overall accuracy of over 
99% and runs multiple times throughout the year. This 
feedback enables providers to improve performance 
during the reporting year to improve their MIPS scores. 
They have been certified by the American College of 
Radiology (ACR) to electronically submit quality 
measures data to the National Radiology Data Registry 
(NRDR).

Velocity Follow Up Manager scans radiology reports for 
pending follow up imaging recommendations. This 
enables practices to close the loop on incomplete 
imaging workups. This helps prevent scheduling 
leakage, reclaim lost revenue, and mitigate liability that 
could arise from lost follow-up procedures. The solution 
is HIPAA compliant and uses best in class security 
configurations.

News

2025

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CMS 2024 Submission Deadline Extension

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Guidance Analytics and ImagineSoftware team up to ...

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You want a QCDR for MIPS

Higher 2023 MIPS Penalties is Good News

2022

The CMS 2023 Quality Payment Program Final Rule is...

Presentation: MIPS Overview and Strategies for 202...

The 2023 Quality Payment Program Proposed Rule is ...

Can I take an automatic MIPS exemption in 2022?

Are Higher 2022 MIPS Penalties Good News?

VIDEO: Where we are with MIPS and MACRA in radiolo...

West County Radiological Group Signs Agreement wit...

2021

Guidance Analytics to showcase solutions at RSNA 2...