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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:

  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.
    • 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.
  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: G0058)

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

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

351

Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

376

Functional Status Assessment
for Total Hip Replacement

470

Functional Status After Primary
Total Knee Replacement

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)

*Automatically calculated by CMS from your Medicare claims.

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: G0058)

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_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:

  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: G0058)

ID

Title

Specs

COST_KA_1

Knee Arthroplasty

COST_PHA_1

Elective Primary Hip Arthroplasty

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 (2022)

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

484 (2022)

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

*2023 versions will be available once updated from CMS.

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

Begin your MVP journey today.