MVP: Focusing on Women’s Health

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.
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.

ID	Title	Specs
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Details
112	Breast Cancer Screening	Details
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Details
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Details
309	Cervical Cancer Screening	Details
310	Chlamydia Screening for Women	Details
335	Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)	Details
336	Maternity Care: Postpartum Follow-up and Care Coordination	Details
400	One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation	Details
422	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury	Details
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Details
432	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair	Details
448	Appropriate Workup Prior to Endometrial Ablation	Details
472	Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	Details
475	HIV Screening	Details
487	Screening for Social Drivers of Health	Details
493	Adult Immunization Status	Details
496	Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument	Details
UREQA8	Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved	Not supported by MIPSpro*

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_1	Enhance Engagement of Medicaid and Other Underserved Populations
IA_AHE_12	Practice Improvements that Engage Community Resources to Address Drivers of Health
IA_AHE_3	Promote Use of Patient-Reported Outcome Tools
IA_AHE_9	Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
IA_BE_16	Promote Self-management in Usual Care
IA_BE_4	Engagement of patients through implementation of improvements in patient portal
IA_BMH_11	Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice
IA_BMH_14	Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women
IA_CC_9	Implementation of practices/processes for developing regular individual care plans
IA_EPA_2	Use of telehealth services that expand practice access
IA_MVP	Practice-Wide Quality Improvement in MIPS Value Pathways
IA_PCMH	Electronic submission of Patient Centered Medical Home accreditation
IA_PM_23	Regular review practices in place on targeted patient population needs
IA_PM_6	Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)

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
MSPB_1	Medicare Spending Per Beneficiary (MSPB) Clinician	Details
TPCC_1	Total Per Capita Cost (TPCC)	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.

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_LVITC_2	Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_LVOTC_1	Support Electronic Referral Loops By Sending Health Information Exclusion
PI_LVPP_1	e-Prescribing Exclusion
PI_ONCACB_1	ONC-ACB Surveillance Attestation
PI_ONCDIR_1	ONC Direct Review  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.

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