Nephrology MIPS Quality Measures and Improvement Activities – 2021

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 IdMeasure NameHigh PriorityMeasure TypeMeasure Description
001Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)yeseCQM/CQMPercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.View
039Screening for Osteoporosis for Women Aged 65-85 Years of AgenoProcessPercentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosisView
047Advance Care PlanyesProcessPercentage 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 planView
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OldernoProcessPercentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 monthsView
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderyesProcessPercentage 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 monthsView
110Preventive Care and Screening: Influenza ImmunizationnoProcessPercentage 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 immunizationView
111Pneumococcal Vaccination Status for Older AdultsnoProcessPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccineView
113Colorectal Cancer ScreeningnoProcessPercentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.View
119Diabetes: Medical Attention for NephropathynoProcessThe percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.View
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlannoProcessPercentage 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
View
130Documentation of Current Medications in the Medical RecordyesProcessPercentage 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 administrationView
134Preventive Care and Screening: Screening for Depression and Follow-Up PlannoeCQM/CQMPercentage 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 screenView
154Falls: Risk AssessmentyesProcessPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 monthsView
155Falls: Plan of CareyesProcessPercentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 monthsView
181Elder Maltreatment Screen and Follow-Up PlanyesProcessPercentage 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 screenView
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionnoProcessPercentage 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
236Controlling High Blood PressureyeseCQM/CQMPercentage 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.View
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentednoProcessPercentage 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 indicatedView
342Pain Brought Under Control Within 48 HoursyesOutcomePatients 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 hoursView
394Immunizations for AdolescentsnoProcessThe percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.View
400One-Time Screening for Hepatitis C Virus (HCV) for Patients at RisknoProcessPercentage 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) infectionView
402Tobacco Use and Help with Quitting Among AdolescentsnoProcessThe 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 userView
431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingnoProcessPercentage 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 userView
439Age Appropriate Screening ColonoscopyyesEfficiencyThe percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31View

[divider style=”full”]

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 IdActivity NameActivity WeightingActivity Description
IA_PM_7Use of QCDR for feedback reports that incorporate population healthHighUse of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.View
IA_CC_13Practice Improvements for Bilateral Exchange of Patient InformationMediumEnsure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following:View
IA_BE_15Engagement of Patients, Family, and Caregivers in Developing a Plan of CareMediumEngage 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_2Participation in MOC Part IVMediumIn 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.View
IA_PSPA_6Consultation of the Prescription Drug Monitoring ProgramHighClinicians would attest to reviewing the patients’ history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days. For the transition year, clinicians would attest to 60 percent review of applicable patient’s history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient’s history performance.View
IA_PSPA_21Implementation of fall screening and assessment programsMediumImplementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).View
IA_PSPA_22CDC Training on CDC's Guideline for Prescribing Opioids for Chronic PainHighCompletion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.View
IA_AHE_6Provide Education Opportunities for New CliniciansHighMIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.View

Subscribe to the Healthmonix Advisor for more specialty specific content.

The Healthmonix Advisor is a free weekly news source, connecting you to the latest updates in the value-based care industry.


Tags

HMX_Specialty_2021