MVP: Improving Care for Lower Extremity Joint Repair
Most applicable medical specialty: Orthopedic surgery
The Improving Care for Lower Extremity Joint Repair MVP focuses on the clinical theme of providing fundamental treatment and management of patients with osteoarthritis and lower extremity surgical repair, such as fracture and total joint replacement, to ensure appropriate care and reduce costs.
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.
- This MVP includes an outcome measure calculated by CMS through administrative claims. If you
select it as 1 of your 4 required quality measures, this must be included in your MVP registration.
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.
- 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, 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.
| ID | Title | Specs |
|---|---|---|
| 024 | Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | Details |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | Details |
| 350 | Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | Details |
| 351 | Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | Details |
| 376 | Functional Status Assessment for Total Hip Replacement | Details |
| 470 | Functional Status After Primary Total Knee Replacement | Details |
| 480 | Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS) | Details |
| 487 | Screening for Social Drivers of Health | Details |
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).
| ID | Title |
|---|---|
| IA_AHE_3 | Promote Use of Patient-Reported Outcome Tools |
| 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_CC_7 | Regular training in care coordination |
| IA_CC_9 | Implementation of practices/processes for developing regular individual care plans |
| IA_CC_13 | Practice Improvements to Align with OpenNotes Principles |
| IA_CC_15 | PSH Care Coordination |
| IA_MVP | Practice-Wide Quality Improvement in MIPS Value Pathways |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation |
| IA_PSPA_7 | Use of QCDR data for ongoing practice assessment and improvements |
| IA_PSPA_18 | Measurement and improvement at the practice and panel level |
| IA_PSPA_27 | Invasive Procedure or Surgery Anticoagulation Medication Management |
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.
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:
- 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.
| 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 |
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.