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||hf:tax:specialty_measure_sets|
|001||Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)||yes||eCQM/CQM||Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.||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)||no||Process||Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge||Details|
|008||Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)||no||Process||Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge||Details|
|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||Details|
|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||Details|
|024||Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older||yes||Process||Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication||Details|
|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||Details|
|048||Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older||no||Process||Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months||Details|
|050||Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older||yes||Process||Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months||Details|
|065||Appropriate Treatment for Children with Upper Respiratory Infection (URI)||yes||Process||Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode||Details|
|066||Appropriate Testing for Children with Pharyngitis||yes||Process||Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode||Details|
|076||Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections||yes||Process||Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed||Details|
|093||Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use||yes||Process||Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy||Details|
|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||Details|
|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||Details|
|112||Breast Cancer Screening||no||Process||Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.||Details|
|116||Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis||yes||Process||The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription||Details|
|117||Diabetes: Eye Exam||no||Process||Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.||Details|
|119||Diabetes: Medical Attention for Nephropathy||no||Process||The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.||Details|
|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||Details|
|134||Preventive Care and Screening: Screening for Depression and Follow-Up Plan||no||eCQM/CQM||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||Details|
|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||Details|
|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||Details|
|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||Details|
|187||Stroke and Stroke Rehabilitation: Thrombolytic Therapy||no||Process||Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well||Details|
|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.||Details|
|236||Controlling High Blood Pressure||yes||eCQM/CQM||Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period.||Details|
|238||Use of High-Risk Medications in the Elderly||yes||Process||Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication 2) Percentage of patients who were ordered at least two of the same high-risk medication||Details|
|254||Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain||no||Process||Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location||Details|
|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||Details|
|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||Details|
|342||Pain Brought Under Control Within 48 Hours||yes||Outcome||Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours||Details|
|358||Patient-Centered Surgical Risk Assessment and Communication||yes||Process||Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon||Details|
|402||Tobacco Use and Help with Quitting Among Adolescents||no||Process||The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user||Details|
|404||Anesthesiology Smoking Abstinence||yes||Intermediate Outcome||The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure||Details|
|415||Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older||yes||Efficiency||Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT||Details|
|416||Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years||yes||Efficiency||Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury||Details|
|418||Osteoporosis Management in Women Who Had a Fracture||no||Process||The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture.||Details|
|424||Perioperative Temperature Management||yes||Outcome||Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time||Details|
|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||Details|
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_CC_7||Regular training in care coordination||Medium||Implementation of regular care coordination training.||Details|
|IA_PSPA_2||Participation in MOC Part IV||Medium||In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results.||Details|
|IA_PSPA_15||Implementation of an ASP||Medium||Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: ||Details|
|IA_PSPA_16||Use of decision support and standardized treatment protocols||Medium||Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.||Details|