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.
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, 2023 - December 31, 2023).
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: G0058)
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)
*Automatically calculated by CMS from your Medicare claims.
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: G0058)
Promote Use of Patient-Reported
Regularly Assess Patient Experience of Care and Follow Up on Findings
Use evidence-based decision aids to support shared decision-making.
Regular training in care coordination
Implementation of practices/processes for developing regular individual care plans
Practice Improvements to Align with
PSH Care Coordination
Electronic submission of Patient Centered Medical Home accreditation
Use of QCDR data for ongoing practice assessment and improvements
Measurement and improvement at
the practice and panel level
Invasive Procedure or Surgery
Anticoagulation Medication Management
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
Cost Measures (MVP ID: G0058)
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
- 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)
Query of the Prescription Drug
Monitoring Program (PDMP)
Support Electronic Referral Loops By Sending Health Information
Support Electronic Referral Loops By Receiving and Reconciling Health Information
Health Information Exchange (HIE)
Enabling Exchange Under TEFCA
Provide Patients Electronic Access to
Their Health Information
Immunization Registry Reporting
Syndromic Surveillance Reporting
Electronic Case Reporting
Public Health Registry Reporting
Clinical Data Registry Reporting
Security Risk Analysis
High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides
Actions to Limit or Restrict the
Compatibility of CEHRT
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.
Improvement Activities (All MVPs)
Begin your MVP journey today.