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|
|001||Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)||yes||Intermediate Outcome||Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period||View|
|039||Screening for Osteoporosis for Women Aged 65-85 Years of Age||no||Process||Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis||View|
|046||Medication Reconciliation Post-Discharge||yes||Process||The 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
|109||Osteoarthritis (OA): Function and Pain Assessment||yes||Process||Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain||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|
|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||View|
|126||Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation||no||Process||Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months||View|
|127||Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear||no||Process||Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing||View|
|128||Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan||no||Process||Percentage 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
|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||View|
|131||Pain Assessment and Follow-Up||yes||Process||Percentage 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 present||View|
|134||Preventive Care and Screening: Screening for Depression and Follow-Up Plan||no||Process||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|
|154||Falls: Risk Assessment||yes||Process||Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months||View|
|155||Falls: Plan of Care||yes||Process||Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months||View|
|178||Rheumatoid Arthritis (RA): Functional Status Assessment||no||Process||Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months||View|
|181||Elder Maltreatment Screen and Follow-Up Plan||yes||Process||Percentage 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 screen||View|
|182||Functional Outcome Assessment||yes||Process||Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies||View|
|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||View|
|236||Controlling High Blood Pressure||yes||Intermediate Outcome||Percentage 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 period||View|
|238||Use of High-Risk Medications in the Elderly||yes||Process||Percentage 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
|261||Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness||yes||Process||Percentage 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 dizziness||View|
|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||View|
|342||Pain Brought Under Control Within 48 Hours||yes||Outcome||Patients 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 hours||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|
|412||Documentation of Signed Opioid Treatment Agreement||yes||Process||All 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 record||View|
|414||Evaluation or Interview for Risk of Opioid Misuse||yes||Process||All 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 record||View|
|418||Osteoporosis Management in Women Who Had a Fracture||no||Process||The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture||View|
|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||View|
|236||Controlling High Blood Pressure||yes||Intermediate Outcome||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.||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_PM_7||Use of QCDR for feedback reports that incorporate population health||High||Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.||View|
|IA_PM_10||Use of QCDR data for quality improvement such as comparative analysis reports across patient populations||Medium||Participation in a QCDR clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).||View|
|IA_PM_13||Chronic Care and Preventative Care Management for Empaneled Patients||Medium||In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:- Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;- Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP)93 and the NCQA Heart/Stroke Recognition Program (HSRP)94;- Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;- Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;- Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/orUse reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.||View|
|IA_PSPA_7||Use of QCDR data for ongoing practice assessment and improvements||Medium||Use of QCDR data, for ongoing practice assessment and improvements in patient safety.||View|
|IA_AHE_3||Promote Use of Patient-Reported Outcome Tools||High||Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.||View|