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

Most applicable medical specialties: Neurology, Neurosurgical, Vascular Surgery

The Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP focuses on the clinical theme of providing fundamental prevention and treatment of those patients at risk for or that have had a stroke.

Quality

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, 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: G0054)

ID

Title

Specs

047

Advance Care Plan

187

Stroke and Stroke Rehabilitation:
Thrombolytic Therapy

   Details

236

Controlling High Blood Pressure

326

Atrial Fibrillation and Atrial Flutter:
Chronic Anticoagulation Therapy

344

Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

409

Clinical Outcome Post
Endovascular Stroke Treatment

413

Door to Puncture Time
for Endovascular Stroke Treatment

438

Statin Therapy for the Prevention
and Treatment of Cardiovascular Disease

441

Ischemic Vascular Disease (IVD) All or None
Outcome Measure (Optimal Control)

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: G0054)

ID

Title

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_24

Financial Navigation Programs

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_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

Cost

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.

Cost Measures (MVP ID: G0054)

ID

Title

Specs

COST_IHCI_1

Intracranial Hemorrhage
or Cerebral Infarction

Foundational Layer - Promoting Interoperability

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:

  • 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

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups

484

Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Looking for a different MVP? Head back to our complete listing of MVPs.

Begin your MVP journey today.