How to Select MIPS Quality Measures
Step 1 : Select At Least 1 Outcome Measure
For the MIPS Quality Performance Category, you must report at least one outcome measure. If no outcome measures are applicable to your patient population, then you must select at least one high-priority measure (see Step 2). The outcome measures you report count towards the six measure requirement for the Quality Performance Category. Reporting additional outcome measures beyond the required one will award two (2) bonus points to your Quality Performance Category Score.
Step 2 : Select Applicable High-Priority Measures
If you were able to select an outcome measure in Step 1, this step is optional. Non-outcome high-priority measures are worth one (1) bonus point for the Quality Performance Category. This makes it a smart idea to include as many outcome and/or high-priority measures as possible in your six Quality Performance Category Measures.
Step 3 : Make Sure You Have 6 Measures Selected
If you have not yet selected six measures and are aiming for a positive MIPS Payment Adjustment, select from the other recommended measures. If you report over six measures, CMS will calculate your MIPS Quality Performance Score using your top performing quality measures.
Recommended Quality Measures
| Quality Id | Measure Name | High Priority | Measure Type | Measure Description | hf:tax:specialty_measure_sets | hf:tax:collection_types | |
|---|---|---|---|---|---|---|---|
| 262 | Image Confirmation of Successful Excision of Image-Localized Breast Lesion | yes | Process | Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy | Details | ||
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | yes | Process | Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Details | ||
| 044 | Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | no | Process | Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision | Details | ||
| 047 | Advance Care Plan | yes | Process | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Details | ||
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin | yes | Process | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis | Details | ||
| 076 | Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | yes | Process | Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed | Details | ||
| 110 | Preventive Care and Screening: Influenza Immunization | no | Process | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | Details | ||
| 111 | Pneumococcal Vaccination Status for Older Adults | no | Process | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | Details | ||
| 112 | Breast Cancer Screening | no | Process | Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period. | Details | ||
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | no | Process | Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2 | Details | ||
| 130 | Documentation of Current Medications in the Medical Record | yes | Process | Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration | Details | ||
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | no | eCQM/CQM | Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen | Details | ||
| 164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation | yes | Outcome | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation 24 hours. | Details | ||
| 259 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | yes | Outcome | Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) | Details | ||
| 264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer | no | Process | The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure | Details | ||
| 260 | Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | yes | Outcome | Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 | Details | ||
| 243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | yes | Process | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program | Details | ||
| 238 | Use of High-Risk Medications in the Elderly | yes | Process | Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication 2) Percentage of patients who were ordered at least two of the same high-risk medication | Details | ||
| 236 | Controlling High Blood Pressure | yes | eCQM/CQM | Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period. | Details | ||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | no | Process | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. | Details | ||
| 258 | Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | yes | Outcome | Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) | Details | ||
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | no | Process | Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated | Details | ||
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | no | Process | Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period | Details | ||
| 354 | Anastomotic Leak Intervention | yes | Outcome | Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery | Details | ||
| 374 | Closing the Referral Loop: Receipt of Specialist Report | yes | Process | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Details | ||
| 358 | Patient-Centered Surgical Risk Assessment and Communication | yes | Process | Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon | Details | ||
| 357 | Surgical Site Infection (SSI) | yes | Outcome | Percentage of patients aged 18 years and older who had a surgical site infection (SSI) | Details | ||
| 356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure | yes | Outcome | Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure | Details | ||
| 355 | Unplanned Reoperation within the 30 Day Postoperative Period | yes | Outcome | Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period | Details | ||
| 344 | Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | yes | Outcome | Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 | Details | ||
| 342 | Pain Brought Under Control Within 48 Hours | yes | Outcome | Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours | Details | ||
| 402 | Tobacco Use and Help with Quitting Among Adolescents | no | Process | The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user | Details | ||
| 404 | Anesthesiology Smoking Abstinence | yes | Intermediate Outcome | The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure | Details | ||
| 424 | Perioperative Temperature Management | yes | Outcome | Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time | Details | ||
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | no | Process | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user | Details |
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How to Select MIPS Improvement Activities
Step 1 : Determine how many points are needed for successful reporting
- 40 points: The standard number of required points and the maximum score for this Performance Category.
- 20 points: For small or rural practices, HPSAs, or non-patient facing clinicians/groups.
- 0 points: Certified Patient Centered Medical Homes receive full credit. A Patient Centered Medical Home must be attested to and will not automatically be classified by CMS as such.
Step 2 : Select Improvement Activities
High-weighted activities are worth 20 points, while medium-weight activities are worth 10 points. Participants can select any combination of activities to meet the requirement.
Recommended Improvement Activities
| Activity Id | Activity Name | Activity Weighting | Activity Description | |
|---|---|---|---|---|
| IA_EPA_3 | Collection and use of patient experience and satisfaction data on access | Medium | Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. | Details |
| IA_CC_2-2021 | Implementation of improvements that contribute to more timely communication of test results | Medium | Timely communication of test results defined as timely identification of abnormal test results with timely follow-up. | Details |
| IA_CC_8 | Implementation of documentation improvements for practice/process improvements | Medium | 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). | Details |
| IA_BE_14 | Engage Patients and Families to Guide Improvement in the System of Care | High | Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern. | Details |
| IA_AHE_1 | Engagement of New Medicaid Patients and Follow-up | High | Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity. | Details |