Family 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
009Anti-Depressant Medication ManagementnoProcessPercentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)View
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
305Initiation and Engagement of Alcohol and Other Drug Dependence TreatmentnoProcessPercentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visitView
309Cervical Cancer ScreeningnoProcessPercentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 yearsView
318Falls: Screening for Future Fall RiskyesProcessPercentage of patients 65 years of age and older who were screened for future fall risk during the measurement periodView
321CAHPS for MIPS Clinician/Group SurveyyesSurveyThe Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: • Getting timely care, appointments, and information;
• How well providers Communicate;
• Patient’s Rating of Provider;
• Access to Specialists;
• Health Promotion & Education;
• Shared Decision Making;
• Health Status/Functional Status;
• Courteous and Helpful Office Staff;
• Care Coordination; and
• Stewardship of Patient Resources
View
377Functional Status Assessments for Congestive Heart FailureyesProcessPercentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessmentsView
472Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureyesProcessPercentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.View
475HIV ScreeningnoProcessPercentage of patients 15-65 years of age who have been tested for human immunodeficiency virus (HIV).View
476International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiayesPatient Reported OutcomePercentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.View
001Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)yeseCQM/CQMPercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.View
005Heart 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
006Coronary 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
007Coronary 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
008Heart 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
024Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and OlderyesProcessPercentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communicationView
039Screening for Osteoporosis for Women Aged 65-85 Years of AgenoProcessPercentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosisView
047Advance 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
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OldernoProcessPercentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 monthsView
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderyesProcessPercentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 monthsView
065Appropriate Treatment for Children with Upper Respiratory Infection (URI)yesProcessPercentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episodeView
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
110Preventive 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
111Pneumococcal Vaccination Status for Older AdultsnoProcessPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccineView
112Breast Cancer ScreeningnoProcessPercentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.View
113Colorectal Cancer ScreeningnoProcessPercentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.View
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
117Diabetes: Eye ExamnoProcessPercentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.View
119Diabetes: Medical Attention for NephropathynoProcessThe percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.View
126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationnoProcessPercentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 monthsView
128Preventive 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 encounter

Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
View
130Documentation 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
134Preventive Care and Screening: Screening for Depression and Follow-Up PlannoeCQM/CQMPercentage 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 screenView
154Falls: Risk AssessmentyesProcessPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 monthsView
155Falls: Plan of CareyesProcessPercentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 monthsView
181Elder Maltreatment Screen and Follow-Up PlanyesProcessPercentage 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 screenView
226Preventive 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 24 months AND who received tobacco cessation intervention if identified as a tobacco user.View
236Controlling High Blood PressureyeseCQM/CQMPercentage 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
238Use of High-Risk Medications in the ElderlyyesProcessPercentage 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 medicationView
243Cardiac 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
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
326Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapynoProcessPercentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement periodView
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
337Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response ModifiernoProcessPercentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive testView
338HIV Viral Load SuppressionyesOutcomeThe percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement yearView
342Pain Brought Under Control Within 48 HoursyesOutcomePatients 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 hoursView
370Depression Remission at Twelve MonthsyesOutcomeThe percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.View
374Closing 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
387Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug UsersnoProcessPercentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting periodView
394Immunizations for AdolescentsnoProcessThe percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.View
398Optimal Asthma ControlyesOutcomeComposite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbationView
400One-Time Screening for Hepatitis C Virus (HCV) for Patients at RisknoProcessPercentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infectionView
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisnoProcessPercentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission periodView
402Tobacco 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
418Osteoporosis Management in Women Who Had a FracturenoProcessThe 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
431Preventive 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 24 months AND who received brief counseling if identified as an unhealthy alcohol userView
438Statin 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 performance period.View
441Ischemic 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
443Non-Recommended Cervical Cancer Screening in Adolescent FemalesyesProcessThe percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancerView
444Medication Management for People with AsthmayesProcessThe percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment periodView
464Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate UseyesProcessPercentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobialsView
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)yesProcessPercentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatmentView
477Multimodal Pain ManagementyesProcessPercentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine. Percentage of members 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; and pneumococcal.View
478Functional Status Change for Patients with Neck ImpairmentsyesPatient Reported OutcomeThis is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk- adjusted change in functional status (FS) for patients aged 14+ with neck impairments. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality. *The Neck FS PROM is an item-response theory-based computer adaptive test (CAT). In addition to the CAT version, which provides for reduced patient response burden, it is available as a 10-item short form (static/paper-pencil).View

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