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

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
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
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
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
249Barrett’s EsophagusnoProcessPercentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasiaView
250Radical Prostatectomy Pathology ReportingnoProcessPercentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin statusView
265Biopsy Follow-UpyesProcessPercentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patientView
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
395Lung Cancer Reporting (Biopsy/Cytology Specimens)yesProcessPathology 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 reportView
396Lung Cancer Reporting (Resection Specimens)yesProcessPathology 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 typeView
397Melanoma ReportingyesProcessPathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rateView
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
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisnoProcessPercentage 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 periodView
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
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

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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_2Use of telehealth services that expand practice accessMediumUse 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_17Participation in Population Health ResearchMediumParticipation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.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_19Implementation of formal quality improvement methods, practice changes, or other practice improvement processesMediumAdopt 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:View
IA_PSPA_28Completion of an Accredited Safety or Quality Improvement ProgramMediumCompletion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:View
IA_AHE_5MIPS Eligible Clinician Leadership in Clinical Trials or CBPRMediumMIPS 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_2Participation in a 60-day or greater effort to support domestic or international humanitarian needs.HighParticipation 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

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