Otolaryngology MIPS Quality Measures and Improvement Activities

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
021Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation CephalosporinyesProcessPercentage 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 prophylaxisView
023Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)yesProcessPercentage 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 timeView
046Medication Reconciliation Post-DischargeyesProcessThe 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
View
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
065Appropriate Treatment for Children with Upper Respiratory Infection (URI)yesProcessPercentage 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 episodeView
066Appropriate Testing for Children with PharyngitisyesProcessPercentage 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 episodeView
091Acute Otitis Externa (AOE): Topical TherapyyesProcessPercentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparationsView
093Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseyesProcessPercentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapyView
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
116Avoidance of Antibiotic Treatment in Adults With Acute BronchitisyesProcessThe percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescriptionView
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
131Pain Assessment and Follow-UpyesProcessPercentage 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 presentView
134Preventive Care and Screening: Screening for Depression and Follow-Up PlannoProcessPercentage 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
145Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using FluoroscopyyesProcessFinal 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
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
223Functional Status Change for Patients with General Orthopedic ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)View
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 userView
236Controlling High Blood PressureyesIntermediate OutcomePercentage 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 periodView
238Use of High-Risk Medications in the ElderlyyesProcessPercentage 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
View
261Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessyesProcessPercentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizzinessView
265Biopsy Follow-UpyesProcessPercentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patientView
277Sleep Apnea: Severity Assessment at Initial DiagnosisnoProcessPercentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosisView
279Sleep Apnea: Assessment of Adherence to Positive Airway Pressure TherapynoProcessPercentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measuredView
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
331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)yesProcessPercentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptomsView
332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)yesProcessPercentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosisView
333Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)yesEfficiencyPercentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosisView
355Unplanned Reoperation within the 30 Day Postoperative PeriodyesOutcomePercentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative periodView
356Unplanned Hospital Readmission within 30 Days of Principal ProcedureyesOutcomePercentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedureView
357Surgical Site Infection (SSI)yesOutcomePercentage of patients aged 18 years and older who had a surgical site infection (SSI)View
358Patient-Centered Surgical Risk Assessment and CommunicationyesProcessPercentage 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 surgeonView
374Closing the Referral Loop: Receipt of Specialist ReportyesProcessPercentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referredView
394Immunizations for AdolescentsnoProcessThe percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthdayView
398Optimal Asthma ControlyesOutcomeComposite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbationView
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
404Anesthesiology Smoking AbstinenceyesIntermediate OutcomeThe percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedureView
408Opioid Therapy Follow-up EvaluationyesProcessAll patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical recordView
412Documentation of Signed Opioid Treatment AgreementyesProcessAll patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical recordView
414Evaluation or Interview for Risk of Opioid MisuseyesProcessAll patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical recordView
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
435Quality of Life Assessment For Patients With Primary Headache DisordersyesPatient Reported OutcomePercentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improvedView
440Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to ClinicianyesProcessPercentage 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 pathologistView
444Medication Management for People with AsthmayesProcessThe percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment periodView
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)yesProcessPercentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatmentView
474Zoster (Shingles) VaccinationnoProcessThe percentage of patients aged 50 years and older who have had a Varicella Zoster (shingles) vaccination.View

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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_EPA_3Collection and use of patient experience and satisfaction data on accessMediumCollection 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_2Implementation of improvements that contribute to more timely communication of test resultsMediumTimely communication of test results defined as timely identification of abnormal test results with timely follow-up.View
IA_CC_8Implementation of documentation improvements for practice/process improvementsMediumImplementation 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_14Engage Patients and Families to Guide Improvement in the System of CareHighEngage 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_PSPA_5Annual registration in the Prescription Drug Monitoring ProgramMediumAnnual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.View
IA_AHE_1Engagement of New Medicaid Patients and Follow-upHighSeeing 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

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