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||hf:tax:collection_types|
|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|
|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|
|113||Colorectal Cancer Screening||no||Process||Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.||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|
|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|
|185||Colonoscopy Interval for Patients with a History of Adenomatous Polyps– Avoidance of Inappropriate Use||yes||Process||Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy||Details|
|265||Biopsy Follow-Up||yes||Process||Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient||Details|
|249||Barrett’s Esophagus||no||Process||Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia||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|
|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|
|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|
|275||Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy||no||Process||Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy||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|
|320||Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients||yes||Process||Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report||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|
|374||Closing the Referral Loop: Receipt of Specialist Report||yes||Process||Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred||Details|
|387||Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users||no||Process||Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period||Details|
|400||One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk||no||Process||Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection||Details|
|401||Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis||no||Process||Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission period||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|
|425||Photodocumentation of Cecal Intubation||no||Process||The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination||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|
|438||Statin Therapy for the Prevention and Treatment of Cardiovascular Disease||no||Process||Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the performance period.||Details|
|439||Age Appropriate Screening Colonoscopy||yes||Efficiency||The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31||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_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.||Details|
|IA_CC_2-2021||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.||Details|
|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).||Details|
|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.||Details|
|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.||Details|