MVP: Focusing on Women’s Health
Most applicable medical specialty: Gynecology, obstetrics, urogynecology, nonphysician practitioners, certified nurse mid-wives, nurse practitioners, physician assistants
Focusing on Women’s Health MVP focuses on the clinical theme of providing treatment and management of women’s health.
Quality
To fulfill quality requirements:
- You must select 4 quality measures from the list below
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2025 – December 31, 2025).
- 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 |
| 039 | Screening for Osteoporosis for Women Aged 65-85 Years of Age | Details |
| 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 |
| 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* |
Improvement Activities
To fulfill improvement activity requirements:
1. You must report 1 improvement activity from the list below.
Beginning in 2025, improvement activities don’t have assigned weights.
| ID | Title |
| IA_AHE_1 | Enhance Engagement of Medicaid and Other Underserved Populations |
| IA_AHE_3 | Promote Use of Patient-Reported Outcome Tools |
| IA_AHE_9 | Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols |
| 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_16 | Promote Self-management in Usual Care |
| 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_PM_26 | Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B |
| IA_MVP | Practice-Wide Quality Improvement in MIPS Value Pathways |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation |
| 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) |
| IA_PM_23 | Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines |
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.
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_EP_2_EX_1 | Query of the Prescription Drug Monitoring Program (PDMP) |
| PI_EP_2_EX_2 | Query of the Prescription Drug Monitoring Program (PDMP) Exclusion |
| PI_HIE_1 | Support Electronic Referral Loops By Sending Health Information |
| PI_HIE_4 | Support Electronic Referral Loops By Receiving and Reconciling Health Information |
| PI_HIE_5 | Health Information Exchange (HIE) Bi-Directional Exchange |
| PI_HIE_6 | Enabling Exchange Under TEFCA |
| 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 |
| PI_PEA_1 | Provide Patients Electronic Access to Their Health Information |
| PI_PHCDRR_1 | Immunization Registry Reporting |
| PI_PHCDRR_1_EX_1 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_EX_2 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_EX_3 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_PRE | Immunization Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_1_PROD | Immunization Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_2 | Syndromic Surveillance Reporting |
| PI_PHCDRR_2_PRE | Syndromic Surveillance Reporting Active Engagement Level 1 |
| PI_PHCDRR_2_PROD | Syndromic Surveillance Reporting Active Engagement Level 2 |
| PI_PHCDRR_3 | Electronic Case Reporting |
| PI_PHCDRR_3_EX_1 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_EX_2 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_EX_3 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_PRE | Electronic Case Reporting Active Engagement Level 1 |
| PI_PHCDRR_3_PROD | Electronic Case Reporting Active Engagement Level 2 |
| PI_PHCDRR_4 | Public Health Registry Reporting |
| PI_PHCDRR_4_PRE | Public Health Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_4_PROD | Public Health Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_5 | Clinical Data Registry Reporting |
| PI_PHCDRR_5_PRE | Clinical Data Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_5_PROD | Clinical Data Registry Reporting Active Engagement Level 2 |
| PI_PPHI_1 | Security Risk Analysis |
| PI_PPHI_2 | SAFER Guides High Priority Practices Guide |
Foundational Layer – Population Health
- You won’t be required to select a population health measure during registration. This is different from the 2024 MVP registration process requiring you to select a population health measure. You don’t have to submit any data for this measure, we will calculate all available 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 |