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|
|065||Appropriate Treatment for Children with Upper Respiratory Infection (URI)||yes||Process||Percentage 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 episode||View|
|066||Appropriate Testing for Children with Pharyngitis||yes||Process||Percentage 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 episode||View|
|093||Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use||yes||Process||Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy||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|
|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||View|
|137||Melanoma: Continuity of Care – Recall System||yes||Structure||Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment||View|
|138||Melanoma: Coordination of Care||yes||Process||Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis||View|
|143||Oncology: Medical and Radiation – Pain Intensity Quantified||yes||Process||Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.||View|
|144||Oncology: Medical and Radiation – Plan of Care for Moderate to Severe Pain||yes||Process||Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician||View|
|145||Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy||yes||Process||Final 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|
|147||Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy||yes||Process||Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed||View|
|205||HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis||no||Process||Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection||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|
|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|
|268||Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy||no||Process||All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year||View|
|335||Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse)||yes||Outcome||Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication.||View|
|336||Maternity Care: Post-Partum Follow-Up and Care Coordination||yes||Process||Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care within 8 weeks of giving birth and who received a breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update||View|
|337||Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier||no||Process||Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test||View|
|358||Patient-Centered Surgical Risk Assessment and Communication||yes||Process||Percentage 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 surgeon||View|
|386||Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences||yes||Process||Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually||View|
|387||Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users||no||Process||Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period||View|
|391||Follow-Up After Hospitalization for Mental Illness (FUH)||yes||Process||The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner.||View|
|394||Immunizations for Adolescents||no||Process||The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.||View|
|398||Optimal Asthma Control||yes||Outcome||Composite 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 exacerbation||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|
|410||Psoriasis: Clinical Response to Systemic Medications||yes||Outcome||Percentage of psoriasis vulgaris patients receiving systemic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment||View|
|444||Medication Management for People with Asthma||yes||Process||The 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 period||View|
|464||Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use||yes||Process||Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials||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_3||Collection and use of patient experience and satisfaction data on access||Medium||Collection 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_2-2021||Implementation of improvements that contribute to more timely communication of test results||Medium||Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.||View|
|IA_CC_8||Implementation of documentation improvements for practice/process improvements||Medium||Implementation 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_14||Engage Patients and Families to Guide Improvement in the System of Care||High||Engage 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_AHE_1||Engagement of New Medicaid Patients and Follow-up||High||Seeing 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|