Emergency Medicine 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
107Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentnoProcessPercentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedView
066Appropriate Testing for Children with PharyngitisyesProcessPercentage 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 episodeView
093Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseyesProcessPercentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapyView
116Avoidance of Antibiotic Treatment in Adults With Acute BronchitisyesProcessThe percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescriptionView
187Stroke and Stroke Rehabilitation: Thrombolytic TherapynoProcessPercentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known wellView
254Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal PainnoProcessPercentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy locationView
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentednoProcessPercentage 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 indicatedView
331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)yesProcessPercentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptomsView
332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)yesProcessPercentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosisView
415Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderyesEfficiencyPercentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CTView
416Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 YearsyesEfficiencyPercentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injuryView

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CMS-2021