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|
|001||Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)||yes||Intermediate Outcome||Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period||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|
|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|
|131||Pain Assessment and Follow-Up||yes||Process||Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present||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|
|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|
|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||View|
|250||Radical Prostatectomy Pathology Reporting||no||Process||Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status||View|
|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||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|
|395||Lung Cancer Reporting (Biopsy/Cytology Specimens)||yes||Process||Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report||View|
|396||Lung Cancer Reporting (Resection Specimens)||yes||Process||Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type||View|
|397||Melanoma Reporting||yes||Process||Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate||View|
|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||View|
|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||View|
|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||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|
|440||Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician||yes||Process||Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist||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_17||Participation in Population Health Research||Medium||Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.||View|
|IA_CC_6||Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination||Medium||Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).||View|
|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 IV97. 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. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program,98 National Cardiovascular Data Registry (NCDR) Clinical Quality Coach,99 Quality Practice Initiative Certification Program,100 American Board of Medical Specialties Practice Performance Improvement Module101 or American Society of Anesthesiologists (ASA) Simulation Education Network,102 for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE);103 American Psychiatric Association (APA) Performance in Practice modules.104||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|
|IA_PSPA_28||Completion of an Accredited Safety or Quality Improvement Program||Medium||Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria:- The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;- The activity must have specific, measurable aim(s) for improvement;- The activity must include interventions intended to result in improvement;- The activity must include data collection and analysis of performance data to assess the impact of the interventions; andThe accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.||View|
|IA_AHE_5||MIPS Eligible Clinician Leadership in Clinical Trials or CBPR||Medium||MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.||View|
|IA_ERP_2||Participation in a 60-day or greater effort to support domestic or international humanitarian needs.||High||Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.||View|