Thoracic Surgery 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

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Quality Id	Measure Name	High Priority	Measure Type	Measure Description
021	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin	yes	Process	Percentage 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 prophylaxis	Details
023	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	yes	Process	Percentage 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 time	Details
047	Advance Care Plan	yes	Process	Percentage 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 plan	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
164	Coronary Artery Bypass Graft (CABG): Prolonged Intubation	yes	Outcome	Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation 24 hours.	Details
167	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure	yes	Outcome	Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.	Details
168	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration	yes	Outcome	Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.	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
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
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	Details
374	Closing the Referral Loop: Receipt of Specialist Report	yes	Process	Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred	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
445	Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)	yes	Outcome	Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.	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