How to Select MIPS Quality Measures
Step 1 : Select At Least 1 Outcome Measure
For the MIPS Quality Performance Category, you must report at least one outcome measure. If no outcome measures are applicable to your patient population, then you must select at least one high-priority measure (see Step 2). The outcome measures you report count towards the six measure requirement for the Quality Performance Category. Reporting additional outcome measures beyond the required one will award two (2) bonus points to your Quality Performance Category Score.
Step 2 : Select Applicable High-Priority Measures
If you were able to select an outcome measure in Step 1, this step is optional. Non-outcome high-priority measures are worth one (1) bonus point for the Quality Performance Category. This makes it a smart idea to include as many outcome and/or high-priority measures as possible in your six Quality Performance Category Measures.
Step 3 : Make Sure You Have 6 Measures Selected
If you have not yet selected six measures and are aiming for a positive MIPS Payment Adjustment, select from the other recommended measures. If you report over six measures, CMS will calculate your MIPS Quality Performance Score using your top performing quality measures.
Recommended Quality Measures
|Quality Id||Measure Name||High Priority||Measure Type||Measure Description|
|130||Documentation of Current Medications in the Medical Record||yes||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||View|
|134||Preventive Care and Screening: Screening for Depression and Follow-Up Plan||no||Process||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||View|
|154||Falls: Risk Assessment||yes||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||View|
|155||Falls: Plan of Care||yes||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||View|
|181||Elder Maltreatment Screen and Follow-Up Plan||yes||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||View|
|226||Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention||no||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||View|
|261||Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness||yes||Process||Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness||View|
|431||Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling||no||Process||Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user||View|
How to Select MIPS Improvement Activities
Step 1 : Determine how many points are needed for successful reporting.
- 40 points: The standard number of required points and the maximum score for this Performance Category.
- 20 points: For small or rural practices, HPSAs, or non-patient facing clinicians/groups.
- 0 points: Certified Patient Centered Medical Homes receive full credit. A Patient Centered Medical Home must be attested to and will not automatically be classified by CMS as such.
Step 2 : Select Improvement Activities
High-weighted activities are worth 20 points, while medium-weight activities are worth 10 points. Participants can select any combination of activities to meet the requirement.
Recommended Improvement Activities
|Activity Id||Activity Name||Activity Weighting||Activity Description|
|IA_EPA_2||Use of telehealth services that expand practice access||Medium||Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.||View|
|IA_PM_15||Implementation of episodic care management practice improvements||Medium||Provide episodic care management, including management across transitions and referrals that could include one or more of the following:Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/orManaging care intensively through new diagnoses, injuries and exacerbations of illness.||View|
|IA_BE_6||Collection and follow-up on patient experience and satisfaction data on beneficiary engagement||High||Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.||View|
|IA_BE_10||Participation in a QCDR that promotes implementation of patient self-action plans.||Medium||Participation in a QCDR that promotes implementation of patient self-action plans.||View|
|IA_BE_15||Engagement of Patients, Family, and Caregivers in Developing a Plan of Care||Medium||Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.||View|
|IA_PSPA_1||Participation in an AHRQ-listed patient safety organization.||Medium||Participation in an AHRQ-listed patient safety organization.||View|
|IA_PSPA_19||Implementation of formal quality improvement methods, practice changes, or other practice improvement processes||Medium||Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following such as: - Multi-Source Feedback; - Train all staff in quality improvement methods; - Integrate practice change/quality improvement into staff duties; - Engage all staff in identifying and testing practices changes; - Designate regular team meetings to review data and plan improvement cycles; - Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or - Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.||View|