Most applicable medical specialties: Preventive Medicine, Internal Medicine, Family Medicine, Geriatrics
The Promoting Wellness MVP focuses on the clinical theme of promoting quality care for patients in order to reduce the risk of diseases, disabilities, and death.
Quality
To fulfill quality requirements:
- You must select 4 quality measures from the list below
(exception for clinicians in a small practice - see # 3 below) - At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- 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.
- You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2023 - December 31, 2023).
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 2023, 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: M0005)
ID
Title
Specs
483*
Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)
Improvement Activities
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: M0005)
ID
Title
IA_AHE_3
Promote Use of Patient-Reported
Outcome Tools
IA_AHE_12
Practice Improvements that Engage Community Resources to Address Drivers of Health
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_12
Use evidence-based decision aids to support shared decision-making.
IA_BMH_9
Unhealthy Alcohol Use for Patients with
Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients
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_EPA_1
Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
IA_PCMH
Electronic submission of Patient Centered Medical Home accreditation
IA_PM_11
Regular review practices in place on targeted patient population needs
IA_PM_13
Chronic Care and Preventative Care Management for Empaneled Patients
IA_PM_16
Implementation of medication
management practice improvements
IA_PSPA_19
Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
Cost
Important information to consider:
- 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.) - You'll only be scored on the cost measures in this MVP for which you meet or exceed the established
case minimum.
Cost Measures (MVP ID: M0005)
ID
Title
Specs
Foundational Layer - Promoting Interoperability
To fulfill Promoting Interoperability requirements:
- 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.
- 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:
- Physical therapist (PT)
- Occupational therapist (OT)
- Qualified speech-language pathologist (SLP)
- Qualified audiologist (AuD)
- Clinical psychologist
- Registered dietitian (RD) or nutrition professional
- 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
Foundational Layer - Population Health
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 (2022)
Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups
484 (2022)
Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
*2023 versions will be available once updated from CMS.
Looking for a different MVP? Head back to our complete listing of MVPs.
Begin your MVP journey today.