Cardiology MIPS Specialty Measure Set (2022)

CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
0052022 Measure # 005 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)noProcessPercentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital dischargeView
0062022 Measure # 006 Coronary Artery Disease (CAD): Antiplatelet TherapynoProcessPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrelView
0072022 Measure # 007 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)noProcessPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy.View
0082022 Measure # 008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)noProcessPercentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital dischargeView
0472022 Measure # 047 Advance Care PlanyesProcessPercentage 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 planView
1102022 Measure # 110 Preventive 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
1112022 Measure # 111 Pneumococcal Vaccination Status for Older AdultsnoProcessPercentage of patients 66 years of age and older who have ever received a pneumococcal vaccineView
1182022 Measure # 118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)noProcessPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapyView
1282022 Measure # 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlannoProcessPercentage 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 encounterView
1302022 Measure # 130 Documentation 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
2262022 Measure # 226 Preventive 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 the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco userView
2362022 Measure # 236 Controlling High Blood PressureyesIntermediate OutcomePercentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement periodView
2382022 Measure # 238 Use of High-Risk Medications in Older AdultsyesProcessPercentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug classView
2432022 Measure # 243 Cardiac Rehabilitation Patient Referral from an Outpatient SettingyesProcessPercentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR programView
3222022 Measure # 322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery PatientsyesEfficiencyPercentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission periodView
3232022 Measure # 323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)yesEfficiencyPercentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom statusView
3242022 Measure # 324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk PatientsyesEfficiencyPercentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessmentView
3262022 Measure # 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapynoProcessPercentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribedView
3442022 Measure # 344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)yesOutcomePercent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2View
3742022 Measure # 374 Closing the Referral Loop: Receipt of Specialist ReportyesProcessPercentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referredView
4022022 Measure # 402 Tobacco 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
4312022 Measure # 431 Preventive 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 12 months AND who received brief counseling if identified as an unhealthy alcohol userView
4382022 Measure # 438 Statin Therapy for the Prevention and Treatment of Cardiovascular DiseasenoProcessPercentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:
•All patients who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
•Patients aged ≥ 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
•Patients aged 40-75 years with a diagnosis of diabetes
View
4412022 Measure # 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)yesIntermediate OutcomeThe IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization’s total IVD denominator.View

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CMS-2022