2023 MIPS Quality Measures
For information on any of the below measure categories, select the given titles to see a more detailed list.
2023 MIPS Quality Measures
- 2023 MIPS eCQMS
Quality Id | Measure Name | Measure Type | Collection Type | ||
---|---|---|---|---|---|
001 | Diabetes: Hemoglobin A1c Poor Control | ![]() | Process | CQM, eCQM, MVP | Details |
005 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | ![]() | Process | CQM, eCQM, MVP | Details |
006 | Coronary Artery Disease (CAD): Antiplatelet Therapy | ![]() | Process | CQM, MVP | Details |
007 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%) | ![]() | Process | CQM, eCQM, MVP | Details |
008 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | ![]() | Process | CQM, eCQM, MVP | Details |
014 | Age-Related Macular Degeneration (AMD): Dilated Macular Examination | ![]() | Process | CQM | Details |
019 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | ![]() | Process | CQM, eCQM | Details |
039 | Screening for Osteoporosis for Women Aged 65-85 Years of Age | ![]() | Process | CQM, MVP | Details |
047 | Advance Care Plan | ![]() | Process | CQM, MVP | Details |
048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | ![]() | Process | CQM | Details |
050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | ![]() | Process | CQM | Details |
052 | Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | ![]() | Process | CQM | Details |
065 | Appropriate Treatment for Upper Respiratory Infection (URI) | ![]() | Process | CQM, eCQM | Details |
066 | Appropriate Testing for Pharyngitis | ![]() | Process | CQM, eCQM | Details |
093 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | ![]() | Process | CQM | Details |
102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | ![]() | Process | CQM, eCQM | Details |
104 | Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | ![]() | Process | CQM | Details |
110 | Preventive Care and Screening: Influenza Immunization | ![]() | Process | CQM, eCQM, MVP | Details |
111 | Pneumococcal Vaccination Status for Older Adults | ![]() | Process | CQM, eCQM, MVP | Details |
112 | Breast Cancer Screening | ![]() | Process | CQM, eCQM, MVP | Details |
113 | Colorectal Cancer Screening | ![]() | Process | CQM, eCQM, MVP | Details |
116 | Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | ![]() | Process | CQM, MVP | Details |
117 | Diabetes: Eye Exam | ![]() | Process | CQM, eCQM | Details |
118 | Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF <= 40%) | ![]() | Process | CQM, MVP | Details |
126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | ![]() | Process | CQM | Details |
127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | ![]() | Process | CQM | Details |
128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | ![]() | Process | CQM, eCQM, MVP | Details |
130 | Documentation of Current Medications in the Medical Record | ![]() | Process | CQM, eCQM, MVP | Details |
134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | ![]() | Process | CQM, eCQM, MVP | Details |
137 | Melanoma: Continuity of Care – Recall System | ![]() | Process | CQM | Details |
138 | Melanoma: Coordination of Care | ![]() | Process | CQM | Details |
141 | Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | ![]() | Outcome | CQM | Details |
143 | Oncology: Medical and Radiation – Pain Intensity Quantified | ![]() | Process | CQM, eCQM, MVP | Details |
144 | Oncology: Medical and Radiation – Plan of Care for Pain | ![]() | Process | CQM, MVP | Details |
145 | Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy | ![]() | Process | CQM | Details |
147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | ![]() | Process | CQM | Details |
155 | Falls: Plan of Care | ![]() | Process | CQM | Details |
164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation | ![]() | Outcome | CQM | Details |
167 | Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | ![]() | Outcome | CQM | Details |
168 | Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | ![]() | Outcome | CQM | Details |
176 | Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy | ![]() | Process | CQM, MVP | Details |
177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | ![]() | Process | CQM, MVP | Details |
178 | Rheumatoid Arthritis (RA): Functional Status Assessment | ![]() | Process | CQM, MVP | Details |
180 | Rheumatoid Arthritis (RA): Glucocorticoid Management | ![]() | Process | CQM, MVP | Details |
181 | Elder Maltreatment Screen and Follow-Up Plan | ![]() | Process | CQM | Details |
182 | Functional Outcome Assessment | ![]() | Process | CQM | Details |
185 | Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | ![]() | Process | CQM | Details |
187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy | ![]() | Process | CQM, MVP | Details |
191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | ![]() | Outcome | CQM, eCQM | Details |
205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | ![]() | Process | CQM | Details |
217 | Functional Status Change for Patients with Knee Impairments | ![]() | Outcome | CQM | Details |
218 | Functional Status Change for Patients with Hip Impairments | ![]() | Outcome | CQM | Details |
219 | Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | ![]() | Outcome | CQM | Details |
220 | Functional Status Change for Patients with Low Back Impairments | ![]() | Outcome | CQM | Details |
221 | Functional Status Change for Patients with Shoulder Impairments | ![]() | Outcome | CQM | Details |
226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | ![]() | Process | CQM, eCQM, MVP | Details |
236 | Controlling High Blood Pressure | ![]() | Process | CQM, eCQM, MVP | Details |
238 | Use of High-Risk Medications in Older Adults | ![]() | Process | CQM, eCQM, MVP | Details |
243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | ![]() | Process | CQM, MVP | Details |
249 | Barrett's Esophagus | ![]() | Process | CQM | Details |
250 | Radical Prostatectomy Pathology Reporting | ![]() | Process | CQM | Details |
254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | ![]() | Process | CQM, MVP | Details |
259 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) | ![]() | Outcome | CQM | Details |
260 | Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | ![]() | Outcome | CQM | Details |
261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | ![]() | Process | CQM | Details |
264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer | ![]() | Process | CQM | Details |
268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | ![]() | Process | CQM, MVP | Details |
275 | Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | ![]() | Process | CQM | Details |
277 | Sleep Apnea: Severity Assessment at Initial Diagnosis | ![]() | Process | CQM | Details |
279 | Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | ![]() | Process | CQM | Details |
282 | Dementia: Functional Status Assessment | ![]() | Process | CQM, MVP | Details |
283 | Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | ![]() | Process | CQM | Details |
286 | Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | ![]() | Process | CQM, MVP | Details |
288 | Dementia: Education and Support of Caregivers for Patients with Dementia | ![]() | Process | CQM, MVP | Details |
290 | Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease | ![]() | Process | CQM, MVP | Details |
291 | Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease | ![]() | Process | CQM, MVP | Details |
293 | Rehabilitative Therapy Referral for Patients with Parkinson's Disease | ![]() | Process | CQM, MVP | Details |
317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | ![]() | Process | CQM, eCQM | Details |
320 | Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | ![]() | Process | CQM | Details |
322 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | ![]() | Process | CQM | Details |
324 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | ![]() | Process | CQM | Details |
326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | ![]() | Process | CQM, MVP | Details |
331 | Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | ![]() | Process | CQM, MVP | Details |
332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | ![]() | Process | CQM | Details |
335 | Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) | ![]() | Outcome | CQM | Details |
336 | Maternity Care: Postpartum Follow-Up and Care Coordination | ![]() | Process | CQM | Details |
338 | HIV Viral Load Suppression | ![]() | Outcome | CQM | Details |
340 | HIV Medical Visit Frequency | ![]() | Process | CQM | Details |
344 | Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | ![]() | Outcome | CQM, MVP | Details |
350 | Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Nonsurgical) Therapy | ![]() | Process | CQM, MVP | Details |
351 | Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | ![]() | Process | CQM, MVP | Details |
354 | Anastomotic Leak Intervention | ![]() | Outcome | CQM | Details |
355 | Unplanned Reoperation within the 30 Day Postoperative Period | ![]() | Outcome | CQM | Details |
356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure | ![]() | Outcome | CQM | Details |
357 | Surgical Site Infection (SSI) | ![]() | Outcome | CQM | Details |
358 | Patient-Centered Surgical Risk Assessment and Communication | ![]() | Process | CQM | Details |
360 | Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | ![]() | Process | CQM | Details |
364 | Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | ![]() | Process | CQM | Details |
370 | Depression Remission at Twelve Months | ![]() | Outcome | CQM, eCQM | Details |
374 | Closing the Referral Loop: Receipt of Specialist Report | ![]() | Process | CQM, eCQM | Details |
383 | Adherence to Antipsychotic Medications for Individuals with Schizophrenia | ![]() | Process | CQM | Details |
384 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | ![]() | Outcome | CQM | Details |
385 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | ![]() | Outcome | CQM | Details |
386 | Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | ![]() | Process | CQM, MVP | Details |
387 | Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | ![]() | Process | CQM | Details |
389 | Cataract Surgery: Difference Between Planned and Final Refraction | ![]() | Outcome | CQM | Details |
392 | HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | ![]() | Outcome | CQM, MVP | Details |
393 | HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | ![]() | Outcome | CQM, MVP | Details |
394 | Immunizations for Adolescents | ![]() | Process | CQM | Details |
395 | Lung Cancer Reporting (Biopsy/Cytology Specimens) | ![]() | Process | CQM | Details |
396 | Lung Cancer Reporting (Resection Specimens) | ![]() | Process | CQM | Details |
397 | Melanoma Reporting | ![]() | Process | CQM | Details |
398 | Optimal Asthma Control | ![]() | Outcome | CQM, MVP | Details |
400 | One-Time Screening for Hepatitis C Virus (HCV) for all Patients | ![]() | Process | CQM, MVP | Details |
401 | Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | ![]() | Process | CQM | Details |
402 | Tobacco Use and Help with Quitting Among Adolescents | ![]() | Process | CQM | Details |
404 | Anesthesiology Smoking Abstinence | ![]() | Process | CQM, MVP | Details |
405 | Appropriate Follow-up Imaging for Incidental Abdominal Lesions | ![]() | Process | CQM | Details |
406 | Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients | ![]() | Process | CQM | Details |
409 | Clinical Outcome Post-Endovascular Stroke Treatment | ![]() | Outcome | CQM, MVP | Details |
410 | Psoriasis: Clinical Response to Systemic Medications | ![]() | Outcome | CQM | Details |
413 | Door to Puncture Time for Endovascular Stroke Treatment | ![]() | Process | CQM, MVP | Details |
415 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | ![]() | Process | CQM, MVP | Details |
416 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years | ![]() | Process | CQM | Details |
419 | Overuse of Imaging for the Evaluation of Primary Headache | ![]() | Process | CQM, MVP | Details |
420 | Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | ![]() | Outcome | CQM | Details |
421 | Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | ![]() | Process | CQM | Details |
422 | Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | ![]() | Process | CQM | Details |
424 | Perioperative Temperature Management | ![]() | Outcome | CQM, MVP | Details |
430 | Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | ![]() | Process | CQM, MVP | Details |
431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | ![]() | Process | CQM, MVP | Details |
432 | Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | ![]() | Outcome | CQM | Details |
433 | Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | ![]() | Outcome | CQM | Details |
436 | Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | ![]() | Process | CQM | Details |
439 | Age Appropriate Screening Colonoscopy | ![]() | Process | CQM | Details |
440 | Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician | ![]() | Process | CQM | Details |
441 | Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | ![]() | Process | CQM, MVP | Details |
443 | Non-Recommended Cervical Cancer Screening in Adolescent Females | ![]() | Process | CQM | Details |
445 | Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | ![]() | Outcome | CQM | Details |
448 | Appropriate Workup Prior to Endometrial Ablation | ![]() | Process | CQM | Details |
450 | Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer | ![]() | Process | CQM, MVP | Details |
451 | RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | ![]() | Process | CQM, MVP | Details |
452 | Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | ![]() | Process | CQM, MVP | Details |
453 | Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) | ![]() | Process | CQM, MVP | Details |
457 | Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) | ![]() | Outcome | CQM, MVP | Details |
459 | Back Pain After Lumbar Surgery | ![]() | Outcome | CQM | Details |
461 | Leg Pain After Lumbar Surgery | ![]() | Outcome | CQM | Details |
463 | Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) | ![]() | Process | CQM, MVP | Details |
464 | Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | ![]() | Process | CQM | Details |
465 | Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | ![]() | Process | CQM | Details |
468 | Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | ![]() | Process | CQM | Details |
470 | Functional Status After Primary Total Knee Replacement | ![]() | Outcome | CQM, MVP | Details |
471 | Functional Status After Lumbar Surgery | ![]() | Outcome | CQM | Details |
477 | Multimodal Pain Management | ![]() | Process | CQM, MVP | Details |
478 | Functional Status Change for Patients with Neck Impairments | ![]() | Outcome | CQM | Details |
486 | Dermatitis – Improvement in Patient-Reported Itch Severity | ![]() | Outcome | CQM | Details |
485 | Psoriasis – Improvement in Patient-Reported Itch Severity | ![]() | Outcome | CQM | Details |
487 | Screening for Social Drivers of Health | ![]() | Process | CQM | Details |
489 | Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy | ![]() | Process | CQM, MVP | Details |
488 | Kidney Health Evaluation | ![]() | Process | CQM | Details |
490 | Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors | ![]() | Process | CQM | Details |
491 | Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma | ![]() | Process | CQM | Details |
493 | Adult Immunization Status | ![]() | Process | CQM, MVP | 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 | CQM, MVP | Details |
222 | Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma | ![]() | Outcome | CQM | Details |
391 | Follow-up After Hospitalization for Mental Illness (FUH) | ![]() | Process | CQM | Details |
418 | Osteoporosis Management in Women Who Had a Fracture | ![]() | Outcome | CQM | Details |
438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | ![]() | Process | CQM, eCQM, MVP | Details |
483 | Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) | ![]() | Outcome | CQM | Details |
304 | Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | ![]() | Outcome | CQM | Details |
303 | Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | ![]() | Outcome | CQM | Details |
482 | Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate | ![]() | Outcome | CQM | Details |