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 CQMS
  • 2023 MIPS eCQMS
Quality IdMeasure NamePDFMeasure TypeCollection Type
001Diabetes: Hemoglobin A1c Poor ControlProcessCQM, eCQM, MVPDetails
005Heart 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)ProcessCQM, eCQM, MVPDetails
006Coronary Artery Disease (CAD): Antiplatelet TherapyProcessCQM, MVPDetails
007Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%)ProcessCQM, eCQM, MVPDetails
008Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)ProcessCQM, eCQM, MVPDetails
014Age-Related Macular Degeneration (AMD): Dilated Macular ExaminationProcessCQMDetails
019Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareProcessCQM, eCQMDetails
039Screening for Osteoporosis for Women Aged 65-85 Years of AgeProcessCQM, MVPDetails
047Advance Care PlanProcessCQM, MVPDetails
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OlderProcessCQMDetails
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderProcessCQMDetails
052Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator TherapyProcessCQMDetails
065Appropriate Treatment for Upper Respiratory Infection (URI)ProcessCQM, eCQMDetails
066Appropriate Testing for PharyngitisProcessCQM, eCQMDetails
093Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseProcessCQMDetails
102Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer PatientsProcessCQM, eCQMDetails
104Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate CancerProcessCQMDetails
110Preventive Care and Screening: Influenza ImmunizationProcessCQM, eCQM, MVPDetails
111Pneumococcal Vaccination Status for Older AdultsProcessCQM, eCQM, MVPDetails
112Breast Cancer ScreeningProcessCQM, eCQM, MVPDetails
113Colorectal Cancer ScreeningProcessCQM, eCQM, MVPDetails
116Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisProcessCQM, MVPDetails
117Diabetes: Eye ExamProcessCQM, eCQMDetails
118Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF <= 40%)ProcessCQM, MVPDetails
126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationProcessCQMDetails
127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of FootwearProcessCQMDetails
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanProcessCQM, eCQM, MVPDetails
130Documentation of Current Medications in the Medical RecordProcessCQM, eCQM, MVPDetails
134Preventive Care and Screening: Screening for Depression and Follow-Up PlanProcessCQM, eCQM, MVPDetails
137Melanoma: Continuity of Care – Recall SystemProcessCQMDetails
138Melanoma: Coordination of CareProcessCQMDetails
141Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of CareOutcomeCQMDetails
143Oncology: Medical and Radiation – Pain Intensity QuantifiedProcessCQM, eCQM, MVPDetails
144Oncology: Medical and Radiation – Plan of Care for PainProcessCQM, MVPDetails
145Radiology: Exposure Dose Indices Reported for Procedures Using FluoroscopyProcessCQMDetails
147Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone ScintigraphyProcessCQMDetails
155Falls: Plan of CareProcessCQMDetails
164Coronary Artery Bypass Graft (CABG): Prolonged IntubationOutcomeCQMDetails
167Coronary Artery Bypass Graft (CABG): Postoperative Renal FailureOutcomeCQMDetails
168Coronary Artery Bypass Graft (CABG): Surgical Re-ExplorationOutcomeCQMDetails
176Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier TherapyProcessCQM, MVPDetails
177Rheumatoid Arthritis (RA): Periodic Assessment of Disease ActivityProcessCQM, MVPDetails
178Rheumatoid Arthritis (RA): Functional Status AssessmentProcessCQM, MVPDetails
180Rheumatoid Arthritis (RA): Glucocorticoid ManagementProcessCQM, MVPDetails
181Elder Maltreatment Screen and Follow-Up PlanProcessCQMDetails
182Functional Outcome AssessmentProcessCQMDetails
185Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate UseProcessCQMDetails
187Stroke and Stroke Rehabilitation: Thrombolytic TherapyProcessCQM, MVPDetails
191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryOutcomeCQM, eCQMDetails
205HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and SyphilisProcessCQMDetails
217Functional Status Change for Patients with Knee ImpairmentsOutcomeCQMDetails
218Functional Status Change for Patients with Hip ImpairmentsOutcomeCQMDetails
219Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsOutcomeCQMDetails
220Functional Status Change for Patients with Low Back ImpairmentsOutcomeCQMDetails
221Functional Status Change for Patients with Shoulder ImpairmentsOutcomeCQMDetails
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionProcessCQM, eCQM, MVPDetails
236Controlling High Blood PressureProcessCQM, eCQM, MVPDetails
238Use of High-Risk Medications in Older AdultsProcessCQM, eCQM, MVPDetails
243Cardiac Rehabilitation Patient Referral from an Outpatient SettingProcessCQM, MVPDetails
249Barrett's EsophagusProcessCQMDetails
250Radical Prostatectomy Pathology ReportingProcessCQMDetails
254Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal PainProcessCQM, MVPDetails
259Rate 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)OutcomeCQMDetails
260Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)OutcomeCQMDetails
261Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessProcessCQMDetails
264Sentinel Lymph Node Biopsy for Invasive Breast CancerProcessCQMDetails
268Epilepsy: Counseling for Women of Childbearing Potential with EpilepsyProcessCQM, MVPDetails
275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyProcessCQMDetails
277Sleep Apnea: Severity Assessment at Initial DiagnosisProcessCQMDetails
279Sleep Apnea: Assessment of Adherence to Positive Airway Pressure TherapyProcessCQMDetails
282Dementia: Functional Status AssessmentProcessCQM, MVPDetails
283Dementia Associated Behavioral and Psychiatric Symptoms Screening and ManagementProcessCQMDetails
286Dementia: Safety Concern Screening and Follow-Up for Patients with DementiaProcessCQM, MVPDetails
288Dementia: Education and Support of Caregivers for Patients with DementiaProcessCQM, MVPDetails
290Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s DiseaseProcessCQM, MVPDetails
291Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's DiseaseProcessCQM, MVPDetails
293Rehabilitative Therapy Referral for Patients with Parkinson's DiseaseProcessCQM, MVPDetails
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedProcessCQM, eCQMDetails
320Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsProcessCQMDetails
322Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery PatientsProcessCQMDetails
324Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk PatientsProcessCQMDetails
326Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapyProcessCQM, MVPDetails
331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)ProcessCQM, MVPDetails
332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)ProcessCQMDetails
335Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)OutcomeCQMDetails
336Maternity Care: Postpartum Follow-Up and Care CoordinationProcessCQMDetails
338HIV Viral Load SuppressionOutcomeCQMDetails
340HIV Medical Visit FrequencyProcessCQMDetails
344Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)OutcomeCQM, MVPDetails
350Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Nonsurgical) TherapyProcessCQM, MVPDetails
351Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationProcessCQM, MVPDetails
354Anastomotic Leak InterventionOutcomeCQMDetails
355Unplanned Reoperation within the 30 Day Postoperative PeriodOutcomeCQMDetails
356Unplanned Hospital Readmission within 30 Days of Principal ProcedureOutcomeCQMDetails
357Surgical Site Infection (SSI)OutcomeCQMDetails
358Patient-Centered Surgical Risk Assessment and CommunicationProcessCQMDetails
360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesProcessCQMDetails
364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesProcessCQMDetails
370Depression Remission at Twelve MonthsOutcomeCQM, eCQMDetails
374Closing the Referral Loop: Receipt of Specialist ReportProcessCQM, eCQMDetails
383Adherence to Antipsychotic Medications for Individuals with SchizophreniaProcessCQMDetails
384Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of SurgeryOutcomeCQMDetails
385Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of SurgeryOutcomeCQMDetails
386Amyotrophic Lateral Sclerosis (ALS) Patient Care PreferencesProcessCQM, MVPDetails
387Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug UsersProcessCQMDetails
389Cataract Surgery: Difference Between Planned and Final RefractionOutcomeCQMDetails
392HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation AblationOutcomeCQM, MVPDetails
393HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or RevisionOutcomeCQM, MVPDetails
394Immunizations for AdolescentsProcessCQMDetails
395Lung Cancer Reporting (Biopsy/Cytology Specimens)ProcessCQMDetails
396Lung Cancer Reporting (Resection Specimens)ProcessCQMDetails
397Melanoma ReportingProcessCQMDetails
398Optimal Asthma ControlOutcomeCQM, MVPDetails
400One-Time Screening for Hepatitis C Virus (HCV) for all PatientsProcessCQM, MVPDetails
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisProcessCQMDetails
402Tobacco Use and Help with Quitting Among AdolescentsProcessCQMDetails
404Anesthesiology Smoking AbstinenceProcessCQM, MVPDetails
405Appropriate Follow-up Imaging for Incidental Abdominal LesionsProcessCQMDetails
406Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in PatientsProcessCQMDetails
409Clinical Outcome Post-Endovascular Stroke TreatmentOutcomeCQM, MVPDetails
410Psoriasis: Clinical Response to Systemic MedicationsOutcomeCQMDetails
413Door to Puncture Time for Endovascular Stroke TreatmentProcessCQM, MVPDetails
415Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderProcessCQM, MVPDetails
416Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 YearsProcessCQMDetails
419Overuse of Imaging for the Evaluation of Primary HeadacheProcessCQM, MVPDetails
420Varicose Vein Treatment with Saphenous Ablation: Outcome SurveyOutcomeCQMDetails
421Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for RemovalProcessCQMDetails
422Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract InjuryProcessCQMDetails
424Perioperative Temperature ManagementOutcomeCQM, MVPDetails
430Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination TherapyProcessCQM, MVPDetails
431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingProcessCQM, MVPDetails
432Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse RepairOutcomeCQMDetails
433Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse RepairOutcomeCQMDetails
436Radiation Consideration for Adult CT: Utilization of Dose Lowering TechniquesProcessCQMDetails
439Age Appropriate Screening ColonoscopyProcessCQMDetails
440Skin Cancer: Biopsy Reporting Time – Pathologist to ClinicianProcessCQMDetails
441Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)ProcessCQM, MVPDetails
443Non-Recommended Cervical Cancer Screening in Adolescent FemalesProcessCQMDetails
445Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)OutcomeCQMDetails
448Appropriate Workup Prior to Endometrial AblationProcessCQMDetails
450Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast CancerProcessCQM, MVPDetails
451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody TherapyProcessCQM, MVPDetails
452Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal AntibodiesProcessCQM, MVPDetails
453Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)ProcessCQM, MVPDetails
457Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)OutcomeCQM, MVPDetails
459Back Pain After Lumbar SurgeryOutcomeCQMDetails
461Leg Pain After Lumbar SurgeryOutcomeCQMDetails
463Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)ProcessCQM, MVPDetails
464Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate UseProcessCQMDetails
465Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian ArteriesProcessCQMDetails
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)ProcessCQMDetails
470Functional Status After Primary Total Knee ReplacementOutcomeCQM, MVPDetails
471Functional Status After Lumbar SurgeryOutcomeCQMDetails
477Multimodal Pain ManagementProcessCQM, MVPDetails
478Functional Status Change for Patients with Neck ImpairmentsOutcomeCQMDetails
486Dermatitis – Improvement in Patient-Reported Itch SeverityOutcomeCQMDetails
485Psoriasis – Improvement in Patient-Reported Itch SeverityOutcomeCQMDetails
487Screening for Social Drivers of HealthProcessCQMDetails
489Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) TherapyProcessCQM, MVPDetails
488Kidney Health EvaluationProcessCQMDetails
490Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint InhibitorsProcessCQMDetails
491Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaProcessCQMDetails
493Adult Immunization StatusProcessCQM, MVPDetails
024Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and OlderProcessCQM, MVPDetails
222Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaOutcomeCQMDetails
391Follow-up After Hospitalization for Mental Illness (FUH)ProcessCQMDetails
418Osteoporosis Management in Women Who Had a FractureOutcomeCQMDetails
438Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseProcessCQM, eCQM, MVPDetails
483Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)OutcomeCQMDetails
304Cataracts: Patient Satisfaction within 90 Days Following Cataract SurgeryOutcomeCQMDetails
303Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryOutcomeCQMDetails
482Hemodialysis Vascular Access: Practitioner Level Long-term Catheter RateOutcomeCQMDetails