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|
|021||Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin||yes||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||View|
|023||Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)||yes||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||View|
|046||Medication Reconciliation Post-Discharge||yes||Process||The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record|
This measure is reported as three rates stratified by age group:
• Submission Criteria 1: 18-64 years of age
• Submission Criteria 2: 65 years and older
• Total Rate: All patients 18 years of age and older
|047||Advance Care Plan||yes||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||View|
|110||Preventive Care and Screening: Influenza Immunization||no||Process||Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization||View|
|111||Pneumococcal Vaccination Status for Older Adults||no||Process||Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine||View|
|118||Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)||no||Process||Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy||View|
|128||Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan||no||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
|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|
|145||Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy||yes||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)||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|
|236||Controlling High Blood Pressure||yes||Intermediate Outcome||Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period||View|
|317||Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented||no||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||View|
|326||Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy||no||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||View|
|348||HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate||yes||Outcome||Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD||View|
|392||HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation||yes||Outcome||Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender:|
• Submission Age Criteria 1: Females 18-64 years of age
• Submission Age Criteria 2: Males 18-64 years of age
• Submission Age Criteria 3: Females 65 years of age and older
• Submission Age Criteria 4: Males 65 years of age and older
|393||HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision||yes||Outcome||Infection rate following CIED device implantation, replacement, or revision||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_3||Collection and use of patient experience and satisfaction data on access||Medium||Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.||View|
|IA_CC_2||Implementation of improvements that contribute to more timely communication of test results||Medium||Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.||View|
|IA_CC_8||Implementation of documentation improvements for practice/process improvements||Medium||Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).||View|
|IA_BE_14||Engage Patients and Families to Guide Improvement in the System of Care||High||Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient's status, adherence, comprehension, and indicators of clinical concern.||View|
|IA_AHE_1||Engagement of New Medicaid Patients and Follow-up||High||Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.||View|