MVP: Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes

To fulfill quality requirements:

1. You must select 4 quality measures from the list below
   (exception for clinicians in a small practice – see # 3 below)
   
2. At least 1 measure must be an outcome measure
   • If no outcome measures are available, you may report a high priority measure.
     
     TIP: Before selecting an outcomes-based administrative claims measure, make sure your patient population will allow you to meet the case minimum; if not, you’ll receive 0 achievement points for the measure. If you’re unsure if you’ll meet the case minimum, you may want to report an additional outcome measure.
3. If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don’t need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
   
4. You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2024 – December 31, 2024).

TIP: For small practices (participating at the individual, group or subgroup level) reporting Medicare Part B claims measures: To meet data completeness requirements, you’ll need to start reporting the Medicare Part B claims measures in your selected MVP in January 2024, prior to the MVP registration period.

TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don’t meet case minimum or data completeness criteria will earn zero points.

Quality Measures (MVP ID: G0054)

ID	Title	Specs
047	Advance Care Plan	Details
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Details
236	Controlling High Blood Pressure	Details
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Details
344	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	Details
409	Clinical Outcome Post Endovascular Stroke Treatment	Details
413	Door to Puncture Time for Endovascular Stroke Treatment	Details
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Details
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	Details
487	Screening for Social Drivers of Health	Details

You must report 1 of the following 3 options:

1. Two medium weighted improvement activities from the list below, or

2. One high weighted improvement activity from the list below, or

3. The IA_PCMH activity (participation in a certified or recognized patient-centered medical home or a comparable specialty practice).

Improvement Activities (MVP ID: G0054)

ID	Title
IA_AHE_9	Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
IA_BE_1	Use of certified EHR to capture patient reported outcomes
IA_BE_4	Engagement of patients through implementation of improvements in patient portal
IA_BE_6	Regularly Assess Patient Experience of Care and Follow Up on Findings
IA_BE_24	Financial Navigation Programs
IA_BMH_15	Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults
IA_CC_2	Implementation of Improvements that contribute to more timely communication of test results
IA_CC_13	Practice Improvements to Align with OpenNotes Principles
IA_CC_17	Patient Navigator Program
IA_MVP	Practice-Wide Quality Improvement in MIPS Value Pathways
IA_PCMH	Electronic submission of Patient Centered Medical Home accreditation
IA_PM_13	Chronic Care and Preventative Care Management for Empaneled Patients
IA_PM_15	Implementation of episodic care management practice improvements

Important information to consider:

1. You don’t have to submit any data for this performance category. We’ll use Medicare claims data to calculate your cost measure performance.
   • You don’t select cost measures during MVP registration. CMS will calculate your performance on all the cost measures included in the MVP based on available Medicare claims data.
2. You’ll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.

ID	Title	Specs
COST_IHCI_1	Intracranial Hemorrhage or Cerebral Infarction	Details

To fulfill Promoting Interoperability requirements:

1. Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren’t required.
   
   • If you’re reporting as a subgroup, you’ll submit your affiliated group’s data for the Promoting Interoperability performance category.
2. Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.

Clinician Types for Automatic Reweighting:

• Clinical social worker

Special Status for Automatic Reweighting:

• Ambulatory Surgical Center (ASC)-based
• Hospital-based
• Non-patient facing
• Small practice

Promoting Interoperability Performance Category Hardship Exception Qualifications:

• Decertified EHR technology
• Insufficient internet connectivity
• Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
• Lack control over availability of CEHRT (Certified Electronic Health Record Technology)

Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.

Promoting Interoperability Measures (All MVPs)

ID	Title
PI_EP_1	e-prescribing
PI_EP_2	Query of the Prescription Drug Monitoring Program (PDMP)
PI_HEI_1	Support Electronic Referral Loops By Sending Health Information
PI_HEI_4	Support Electronic Referral Loops By Receiving and Reconciling Health Information
PI_HEI_5	Health Information Exchange (HIE) Bi-Directional Exchange
PI_HEI_6	Enabling Exchange Under TEFCA
PI_PEA_1	Provide Patients Electronic Access to Their Health Information
PI_PHCDRR_1	Immunization Registry Reporting
PI_PHCDRR_2	Syndromic Surveillance Reporting
PI_PHCDRR_3	Electronic Case Reporting
PI_PHCDRR_4	Public Health Registry Reporting
PI_PHCDRR_5	Clinical Data Registry Reporting
PI_PPHI_1	Security Risk Analysis
PI_PPHI_2	High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides
PI_INFBLO_1	Actions to Limit or Restrict the Compatibility of CEHRT
PI_ONCDIR_1	ONC Direct Review Attestation
PI_ONCACB_1	ONC-ACB Surveillance Attestation

You must select 1 population health measure at the time of MVP registration.

• You don’t have to submit any data for this measure, CMS will calculate the population health measures for you using administrative claims data.
  
• This measure will be excluded from scoring if the measure doesn’t have a benchmark or meet the case minimum.
  
• Population health isn’t a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.
  
• Subgroups will be evaluated at the affiliated group level.

Improvement Activities (All MVPs)

ID	Title	Specs
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups	Details
484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Details