2021 Topped Out MIPS Quality Measures: Claims Reporting
These measures are capped at 7 points for the 2021 performance period.
CMS defines a topped-out measure as one whose median performance score is 95% or higher and whose performance is “so high and unvarying that meaningful distinctions and improvement in performance can no longer be made.” CMS has established a 4-year timeline for identifying and removing topped-out measures. If a measure is classified as topped-out for 3 consecutive years, it may be removed the 4th year subject to rule-making and public comment period. In the final rule, CMS has added a new criterion for removing measures identified as “extremely topped-out,” that is, measures with an average performance within the 98th to 100th percentile. For these measures, regardless of where they are in the topped out measure lifecycle, CMS may propose to remove them in the following year’s rulemaking cycle. These measures may not follow the 4-year lifecycle that is applicable to other measures.
| Quality Id | Measure Name | Measure Type | Measure Description | hf:tax:specialty_measure_sets | hf:tax:collection_types | |
|---|---|---|---|---|---|---|
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin | Process | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis | Details | ||
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | Process | Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Details | ||
| 024 | Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | Process | Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication | Details | ||
| 047 | Advance Care Plan | Process | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Details | ||
| 048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | Process | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Details | ||
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | Process | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Details | ||
| 052 | Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | Process | Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator | Details | ||
| 014 | Age-Related Macular Degeneration (AMD): Dilated Macular Examination | Process | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period | Details | ||
| 076 | Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | Process | Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed | Details | ||
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | eCQM/CQM | Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen | Details | ||
| 130 | Documentation of Current Medications in the Medical Record | Process | Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration | Details | ||
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | Process | Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2 | Details | ||
| 117 | Diabetes: Eye Exam | Process | Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period. | Details | ||
| 093 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | Process | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Details | ||
| 195 | Radiology: Stenosis Measurement in Carotid Imaging Reports | Process | Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement | Details | ||
| 147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | Process | Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed | Details | ||
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Process | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen | Details | ||
| 155 | Falls: Plan of Care | Process | Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months | Details | ||
| 154 | Falls: Risk Assessment | Process | Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months | Details | ||
| 145 | Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | Process | Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available) | Details | ||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Process | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. | Details | ||
| 249 | Barrett’s Esophagus | Process | Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia | Details | ||
| 250 | Radical Prostatectomy Pathology Reporting | Process | Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status | Details | ||
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Process | Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated | Details | ||
| 320 | Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | Process | Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Details | ||
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | Process | Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period | Details | ||
| 395 | Lung Cancer Reporting (Biopsy/Cytology Specimens) | Process | Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report | Details | ||
| 397 | Melanoma Reporting | Process | Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate | Details | ||
| 425 | Photodocumentation of Cecal Intubation | Process | The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination | Details | ||
| 436 | Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | Process | Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique | Details |