Diagnostic Radiology MIPS Specialty Measure Set (2021)

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
145Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using FluoroscopyyesProcessFinal 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
147Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone ScintigraphyyesProcessPercentage 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 performedView
195Radiology: Stenosis Measurement in Carotid Imaging ReportsnoProcessPercentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurementView
225Radiology: Reminder System for Screening MammogramsyesStructurePercentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogramView
360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesyesProcessPercentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current studyView
364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesyesProcessPercentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians)View
406Appropriate Follow-up Imaging for Incidental Thyroid Nodules in PatientsyesProcessPercentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommendedView
436Radiation Consideration for Adult CT: Utilization of Dose Lowering TechniquesnoProcessPercentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction techniqueView

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CMS-2021