General Surgery 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
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
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
2642022 Measure # 264 Sentinel Lymph Node Biopsy for Invasive Breast CancernoProcessThe percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedureView
3542022 Measure # 354 Anastomotic Leak InterventionyesOutcomePercentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgeryView
3552022 Measure # 355 Unplanned Reoperation within the 30 Day Postoperative PeriodyesOutcomePercentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative periodView
3562022 Measure # 356 Unplanned Hospital Readmission within 30 Days of Principal ProcedureyesOutcomePercentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedureView
3572022 Measure # 357 Surgical Site Infection (SSI)yesOutcomePercentage of patients aged 18 years and older who had a surgical site infection (SSI)View
3582022 Measure # 358 Patient-Centered Surgical Risk Assessment and CommunicationyesProcessPercentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeonView
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

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Tags

CMS-2022