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Obstetrics / Gynecology 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 Descriptionhf:tax:specialty_measure_setshf:tax:collection_types
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:Details
3102022 MIPS Measure #310: Chlamydia Screening for WomeneCQMPercentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement periodDetails
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 periodDetails
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 HIVDetails
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 planDetails
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 monthsDetails
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 immunizationDetails
1112022 Measure # 111 Pneumococcal Vaccination Status for Older AdultsnoProcessPercentage of patients 66 years of age and older who have ever received a pneumococcal vaccineDetails
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.Details
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 encounterDetails
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 administrationDetails
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 userDetails
2652022 Measure # 265 Biopsy Follow-UpyesProcessPercentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.Details
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 periodDetails
3352022 Measure # 335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)yesOutcomePercentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.Details
3362022 Measure # 336 Maternity Care: Postpartum Follow-Up and Care CoordinationyesProcessPercentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and updateDetails
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 referredDetails
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 userDetails
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 fractureDetails
4222022 Measure # 422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract InjuryyesProcessPercentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapseDetails
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 userDetails
4322022 Measure # 432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse RepairyesOutcomePercentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgeryDetails
4332022 Measure # 433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse RepairyesOutcomePercentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgeryDetails
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 cancerDetails
4482022 Measure # 448 Appropriate Workup Prior to Endometrial AblationyesProcessPercentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.Details
4772022 Measure # 477 Multimodal Pain ManagementyesProcessPercentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicineDetails

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