MIPS Quality Performance Category | Submission Options & Scoring 2020

Quality performance category
2020 MIPS

Select 6 measures
1 outcome or high-priority measure
Alternatively, a specialty or sub-specialty measure set may be used
Report 70% of applicable visits from a full calendar year
Population measure automatically calculated, if applicable

45 %

MIPS Final Score

Key changes from 2019

Click each option to learn more!

Data completeness threshold increased from 60% to 70% of clinician's or group' patient across all payers for the performance period

Modified Benchmarks to Avoid Potential Patient Risk

Removed 42 measures, revised 83, and added 4 new Quality measures

MIPS 2020 Quality measures added:

MIPS Measure #475: HIV Screening
MIPS Measure #476: International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
MIPS Measure #477: Multimodal Pain Management
MIPS Measure #478: Functional Status Change for Patients with Neck Impairments

MIPS Quality measures removed for 2020 ( IDs 046, 51, 68, 91, 109, 131, 160, 165, 166, 179, 192, 223, 255, 262, 271, 325, 328, 329, 330, 343, 345, 346, 347, 352, 353, 361, 362, 371, 372, 388, 403, 407, 411, 417, 428, 442, 446, 449, 454, 456, 467, 474):

MIPS Measure #046: Medication Reconciliation Post-Discharge

MIPS Measure #051: Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

MIPS Measure #068: Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy

MIPS Measure #091: Acute Otitis Externa (AOE): Topical Therapy

MIPS Measure #109: Osteoarthritis (OA): Function and Pain Assessment

MIPS Measure #131: Pain Assessment and Follow-Up

MIPS Measure #160: HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis

MIPS Measure #165: Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

MIPS Measure #166: Coronary Artery Bypass Graft (CABG): Stroke

MIPS Measure #179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

MIPS Measure #192: Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

MIPS Measure #223: Functional Status Change for Patients with General Orthopedic Impairments

MIPS Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

MIPS Measure #262: Image Confirmation of Successful Excision of Image-Localized Breast Lesion

MIPS Measure #271: Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment

MIPS Measure #325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

MIPS Measure #328: Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL

MIPS Measure #329: Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis

MIPS Measure #330: Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days

MIPS Measure #343: Screening Colonoscopy Adenoma Detection Rate

MIPS Measure #345: Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive

MIPS Measure #346: Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive

MIPS Measure #347: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive

MIPS Measure #352: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet

MIPS Measure #353: Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report

MIPS Measure #361: Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry

MIPS Measure #362: Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes

MIPS Measure #371: Depression Utilization of the PHQ-9 Tool

MIPS Measure #372: Maternal Depression Screening

MIPS Measure #388: Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)MIPS Measure #403: Adult Kidney Disease: Referral to Hospice

MIPS Measure #407: Appropriate Treatment of Methicillin-Susceptible Staphylococcus Aureus (MSSA) Bacteremia

MIPS Measure #411: Depression Remission at Six Months

MIPS Measure #417: Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive

MIPS Measure #428: Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

MIPS Measure #442: Persistence of Beta-Blocker Treatment After a Heart Attack

MIPS Measure #446: Operative Mortality Stratified by the Five STS-EACTS Mortality Categories

MIPS Measure #449: HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies

MIPS Measure #454: Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score – better)

MIPS Measure #456: Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score – better)

MIPS Measure #467: Developmental Screening in the First Three Years of Life

MIPS Measure #474: Zoster (Shingles) Vaccination

Topped Out Measures in 2020 - these measures will receive a maximum score of 7 points

Measure Title	Measure ID	Collection Type
Documentation of Current Medications in the Medical Record	130	eCQM
Oncology: Medical and Radiation - Pain Intensity Quantified	143	eCQM
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	12	Medicare Part B Claims
Age-Related Macular Degeneration (AMD): Dilated Macular Examination	14	Medicare Part B Claims
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second-Generation Cephalosporin	21	Medicare Part B Claims
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	23	Medicare Part B Claims
Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	24	Medicare Part B Claims
Advance Care Plan	47	Medicare Part B Claims
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	48	Medicare Part B Claims
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	50	Medicare Part B Claims
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy	52	Medicare Part B Claims
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	76	Medicare Part B Claims
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use	93	Medicare Part B Claims
Diabetes: Eye Exam	117	Medicare Part B Claims
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	128	Medicare Part B Claims
Documentation of Current Medications in the Medical Record	130	Medicare Part B Claims
Preventive Care and Screening: Screening for Depression and Follow-Up Plan	134	Medicare Part B Claims
Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy	145	Medicare Part B Claims
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy	147	Medicare Part B Claims
Falls: Risk Assessment	154	Medicare Part B Claims
Falls: Plan of Care	155	Medicare Part B Claims
Elder Maltreatment Screen and Follow-Up Plan	181	Medicare Part B Claims
Functional Outcome Assessment	182	Medicare Part B Claims
Radiology: Stenosis Measurement in Carotid Imaging Reports	195	Medicare Part B Claims
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	226	Medicare Part B Claims
Barrett's Esophagus	249	Medicare Part B Claims
Radical Prostatectomy Pathology Reporting	250	Medicare Part B Claims
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	317	Medicare Part B Claims
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	320	Medicare Part B Claims
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	326	Medicare Part B Claims
Lung Cancer Reporting (Biopsy/Cytology Specimens)	395	Medicare Part B Claims
Melanoma Reporting	397	Medicare Part B Claims
Photodocumentation of Cecal Intubation	425	Medicare Part B Claims
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques	436	Medicare Part B Claims
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	8	MIPS CQM
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	12	MIPS CQM
Age-Related Macular Degeneration (AMD): Dilated Macular Examination	14	MIPS CQM
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	19	MIPS CQM
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second-Generation Cephalosporin	21	MIPS CQM
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	23	MIPS CQM
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery	44	MIPS CQM
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy	52	MIPS CQM
Appropriate Treatment for Children with Upper Respiratory Infection (URI)	65	MIPS CQM
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	76	MIPS CQM
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use	93	MIPS CQM
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	102	MIPS CQM
Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer	104	MIPS CQM
Diabetes: Eye Exam	117	MIPS CQM
Documentation of Current Medications in the Medical Record	130	MIPS CQM
Melanoma: Coordination of Care	138	MIPS CQM
Oncology: Medical and Radiation - Pain Intensity Quantified	143	MIPS CQM
Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy	145	MIPS CQM
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy	147	MIPS CQM
Falls: Risk Assessment	154	MIPS CQM
Rheumatoid Arthritis (RA): Functional Status Assessment	178	MIPS CQM
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use	185	MIPS CQM
Stroke and Stroke Rehabilitation: Thrombolytic Therapy	187	MIPS CQM
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	191	MIPS CQM
Radiology: Stenosis Measurement in Carotid Imaging Reports	195	MIPS CQM
Barrett's Esophagus	249	MIPS CQM
Radical Prostatectomy Pathology Reporting	250	MIPS CQM
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain	254	MIPS CQM
Sentinel Lymph Node Biopsy for Invasive Breast Cancer	264	MIPS CQM
Biopsy Follow-Up	265	MIPS CQM
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy	279	MIPS CQM
Dementia: Functional Status Assessment	282	MIPS CQM
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management	283	MIPS CQM
Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	286	MIPS CQM
Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease	291	MIPS CQM
Parkinson's Disease: Rehabilitative Therapy Options	293	MIPS CQM
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	320	MIPS CQM
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	326	MIPS CQM
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	332	MIPS CQM
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy	350	MIPS CQM
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation	351	MIPS CQM
Patient-Centered Surgical Risk Assessment and Communication	358	MIPS CQM
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies	360	MIPS CQM
Closing the Referral Loop: Receipt of Specialist Report	374	MIPS CQM
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery	384	MIPS CQM
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options	390	MIPS CQM
Lung Cancer Reporting (Biopsy/Cytology Specimens)	395	MIPS CQM
Lung Cancer Reporting (Resection Specimens)	396	MIPS CQM
Melanoma Reporting	397	MIPS CQM
Tobacco Use and Help with Quitting Among Adolescents	402	MIPS CQM
Opioid Therapy Follow-up Evaluation	408	MIPS CQM
Documentation of Signed Opioid Treatment Agreement	412	MIPS CQM
Evaluation or Interview for Risk of Opioid Misuse	414	MIPS CQM
Perioperative Temperature Management	424	MIPS CQM
Photodocumentation of Cecal Intubation	425	MIPS CQM
Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy	430	MIPS CQM
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques	436	MIPS CQM
Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician	440	MIPS CQM
Medication Management for People with Asthma	444	MIPS CQM
Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)	463	MIPS CQM
Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	464	MIPS CQM
Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	464	MIPS CQM

MIPS Quality Measures 2020

Quality Performance Category Submission Options

An organization may choose to submit measure data to CMS as an individual or as a group through any of the options below.

Collection Type	Individual Submisson	Group Submission
Clinical Quality Measures ( Formerly Qualified Registries)
QCDR Measures
Electronic Clinical Quality Measures (Formerly EHR Measures)
Medicare Part B Claims*
CMS Web Interface
CAHPS for MIPS Survey
Administrative Claims

*Medicare Part B claims measures can only be submitted by clinicians in a small practice (15 or fewer eligible clinicians) whether participating individually or as part of a group.

What contributes to the Quality performance category score?

As Quality is worth 45% of your total MIPS composite performance score, understanding how to excel in this category is important. Measure performance compared to benchmarks, bonus points, performance improvement, and the small practice bonus will all impact your Quality score.

PERFORMANCE

1-10 Points per reported measure

BONUS

Additional Outcome/ High-Priority Measures
End-to-end electronic reporting
Small Practice Bonus
Performance Improvement

Add together points scored and divide by 60 or 70 (for groups eligible for the All-Cause Hospital Readmission measure) to get the final quality score. (This does not apply for EMA-eligible practices.)
If less than 6 measures are selected, clinicians will receive 0 points for missing measures.
Quality measures that meet the minimum case requirement (20 eligible instances), 60% data completeness threshold, and have a benchmark will be worth between 3-10 points.
If a measure has no benchmark or does not meet the minimum case requirement, it will only receive 3 points. If a measure does not meet the data completeness threshold of 70%, it will only receive 0 point or 3 points (small practices).

Bonus point categories are capped at 10% of the total possible quality score. This is 7 points for groups eligible for the All-Hospital Readmission Measure, and 6 points in all other circumstances.

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