Pathology 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

Search:

Quality Id	Measure Name	High Priority	Measure Type	Measure Description
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
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
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
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
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
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	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
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
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	Details
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	Details
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	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
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
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	Details

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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