Family Medicine 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
4752022 MIPS Measure #475: HIV ScreeningeCQMPercentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIVView
3092022 MIPS Measure #309: Cervical Cancer ScreeningeCQMPercentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:View
3052022 MIPS Measure #305: Initiation and Engagement of Alcohol and Other Drug Dependence TreatmenteCQMPercentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.View
1072022 MIPS Measure #107: Adult Major Depressive Disorder (MDD): Suicide Risk AssessmenteCQMAll patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visitView
3182022 MIPS Measure # 318: Falls: Screening for Future Fall RiskeCQMPercentage of patients 65 years of age and older who were screened for future fall risk during the measurement periodView
4722022 MIPS Measure #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureeCQMPercentage 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 periodView
0012022 Measure # 001 Diabetes: Hemoglobin A1c Poor ControlyesIntermediate OutcomePercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.View
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
0242022 Measure # 024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and OlderyesProcessCommunication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and OlderView
0392022 Measure # 039 Screening 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
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
0482022 Measure # 048 Urinary 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
0652022 Measure # 065 Appropriate Treatment for Upper Respiratory Infection (URI)yesProcessPercentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing eventView
0662022 Measure # 066 Appropriate Testing for PharyngitisyesProcessThe percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) testView
0932022 Measure # 093 Acute 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
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
1122022 Measure # 112 Breast 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
1132022 Measure # 113 Colorectal Cancer ScreeningnoProcessPercentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.View
1162022 Measure # 116 Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisyesProcessThe percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescriptionView
1172022 Measure # 117 Diabetes: Eye ExamnoProcessPercentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of 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 in any part of 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
1192022 Measure # 119 Diabetes: 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
1262022 Measure # 126 Diabetes 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
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
1342022 Measure # 134 Preventive Care and Screening: Screening for Depression and Follow-Up PlannoProcessPercentage of patients aged 12 years and older screened for depression on the date of the encounter or 14 days prior to 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 eligible encounterView
1552022 Measure # 155 Falls: 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
1812022 Measure # 181 Elder 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
1822022 Measure # 182 Functional Outcome AssessmentyesProcessPercentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.View
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
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
3312022 Measure # 331 Adult 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
3322022 Measure # 332 Adult 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
3382022 Measure # 338 HIV 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
3702022 Measure # 370 Depression 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
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
3832022 Measure # 383 Adherence to Antipsychotic Medications for Individuals with SchizophreniayesIntermediate OutcomePercentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance periodView
3872022 Measure # 387 Annual 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
3942022 Measure # 394 Immunizations for AdolescentsnoProcessThe percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.View
3982022 Measure # 398 Optimal 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
4002022 Measure # 400 One-Time Screening for Hepatitis C Virus (HCV) for all PatientsnoProcessPercentage 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
4012022 Measure # 401 Hepatitis 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
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
4182022 Measure # 418 Osteoporosis 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 fractureView
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
4432022 Measure # 443 Non-Recommended Cervical Cancer Screening in Adolescent FemalesyesProcessThe percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancerView
4642022 Measure # 464 Otitis Media with Effusion: Systemic AntimicrobialsyesProcessPercentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobialsView
4682022 Measure # 468 Continuity 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
4772022 Measure # 477 Multimodal Pain ManagementyesProcessPercentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicineView

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CMS-2022