2025 COLLECTION TYPE:
MIPS CLINICAL QUALITY MEASURES (CQMS)
Description:
Percentage of patients who received age-and sex-appropriate preventive screenings and wellness services. This measure is a composite of seven component measures that are based on recommendations for preventive care by the U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), American Association of Clinical Endocrinology (AACE), and American College of Endocrinology (ACE).
Instructions:
This composite measure is to be submitted a minimum of once per performance period for patients seen during the performance period. However, the individual performance rates have different submission frequencies. This composite measure is intended to reflect the quality of services provided for preventative care and wellness. This composite measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. For accountability reporting in the CMS MIPS program, all seven performance rates must be submitted, and a weighted average will be used for performance.
This measure will be calculated with 7 performance rates:
- Percentage of patients who received an influenza immunization or who reported previous receipt of an influenza immunization
- Percentage of patients 65 years of age or older who received a pneumococcal vaccination on or after their 19th birthday
- Percentage of patients with a mammogram during the 27 months prior to the end of the measurement period
- Percentage of patients with one or more appropriate colorectal cancer screenings
- Percentage of patients with a documented Body Mass Index (BMI), with follow-up plan if applicable, during the encounter or during the previous 12 months
- Percentage of patients screened for tobacco use and, if identified as a tobacco user, received cessation intervention during the encounter or within the previous six months
- Percentage of visits where patients were screened for high blood pressure with a documented follow-up plan, as indicated
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable except for Submission Criteria 5 and Submission Criteria 7. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
SUBMISSION CRITERIA 1: ALL PATIENTS WHO WERE SCREENED FOR INFLUENZA VACCINATION
Denominator (Submission Criteria 1):
All patients aged 6 months and older seen for a visit during the measurement period
DENOMINATOR NOTE: For the purposes of the program, in order to submit on the flu season 2024-2025, the patient must have a qualifying encounter between January 1 and March 31, 2025. In order to submit on the flu season 2025-2026, the patient must have a qualifying encounter between October 1 and December 31, 2025. A qualifying encounter needs to occur within the flu season that is being submitted; any additional encounter(s) may occur at any time within the measurement period.
*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases 1):
Patients aged ≥ 6 months
AND
Patient encounter during January thru March and/or October thru December (CPT or HCPCS): 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99421, 99422, 99423, 99429*, 99457, 99512*, G0438, G0439, G2250, G2251, G2252
AND NOT
DENOMINATOR EXCLUSIONS:
Hospice services provided to patient any time during the measurement period: M1303
OR
Anaphylaxis due to the vaccine on or before the date of the encounter: M1311
Numerator (Submission Criteria 1):
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization
Definition:
Previous Receipt – Receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st).
Numerator Instructions:
The numerator for this measure can be met by submitting either administration of an influenza vaccination or that the patient reported previous receipt of the current season’s influenza immunization. If the performance of the numerator is not met, a MIPS eligible clinician can submit a valid denominator exception for having not administered an influenza vaccination. For MIPS eligible clinicians submitting a denominator exception for this measure, there should be a clear rationale and documented reason for not administering an influenza immunization if the patient did not indicate previous receipt, which could include a medical reason (e.g., patient allergy), patient reason (e.g., patient declined), or system reason (e.g., vaccination not available). The system reason should be indicated only for cases of disruption or shortage of influenza vaccination supply.
NUMERATOR NOTE: Denominator Exception(s) are determined at the time of the denominator eligible encounter during the current flu season.
Numerator Options:
Performance Met: Influenza immunization administered or previously received (M1299)
OR
Denominator Exception: Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) (M1300)
OR
Performance Not Met: Influenza immunization was not administered, reason not given (M1308)
AND
SUBMISSION CRITERIA 2: ALL PATIENTS WHO WERE SCREENED FOR PNEUMOCOCCAL VACCINATION STATUS FOR OLDER ADULTS
Denominator (Submission Criteria 2):
Patients 65 years of age and older with a visit during the measurement period
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90945, 90947, 90960, 90961, 90962, 90966, 90970, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99421, 99422, 99423, 99429*, 99457, 99512*, G0438, G0439, G2250, G2251, G2252
AND NOT
DENOMINATOR EXCLUSIONS:
Patient had anaphylaxis due to the pneumococcal vaccine any time during or before the measurement period: M1306
OR
Hospice services provided to patient any time during the measurement period: M1303
Numerator (Submission Criteria 2):
Patients who were administered any pneumococcal conjugate vaccine or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period
NUMERATOR NOTE: The measure provides credit for adults 65 years of age and older who have received any pneumococcal vaccine on or after the patient’s 19th birthday.
Patient reported vaccine receipt, when recorded in the medical record, is acceptable for meeting the numerator.
Numerator Options:
Performance Met: Patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period (M1305)
OR
Performance Not Met: Patient did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period (M1304)
AND
SUBMISSION CRITERIA 3: ALL PATIENTS WHO WERE SCREENED FOR BREAST CANCER DENOMINATOR (SUBMISSION CRITERIA 3):
Women 41-74 years of age with a visit during the measurement period
DENOMINATOR NOTE: The intent of this measure component is that starting at age 40 women should have one or more mammograms every 24 months with a 3-month grace period. The intent of the exclusion for individuals age 66 and older residing in long-term care facilities, including nursing homes, is to exclude individuals who may have limited life expectancy and increased frailty where the benefit of the process may not exceed the risks. This exclusion is not intended as a clinical recommendation regarding whether the measures process is inappropriate for specific populations, instead the exclusion allows clinicians to engage in shared decision making with patients about the benefits and risks of screening when an individual has limited life expectancy.
To assess the age for exclusions, the patient’s age on the date of the encounter should be used. *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients 41 to 74 years of age at the beginning of the measurement period
AND
Patient encounter during the performance period (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99386*, 99387*, 99396*, 99397*, 99421, 99422, 99423, 99457, G0438, G0439, G2250, G2251, G2252
AND NOT
DENOMINATOR EXCLUSIONS:
Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy: M1280
OR
Hospice services provided to patient any time during the measurement period: M1303
OR
Palliative care services provided to patient any time during the measurement period: M1309
OR
Patients age 66 or older in Institutional Special Needs Plans (SNP) or residing in long term care with POS code 32, 33, 34, 54, or 56 for more than 90 consecutive days during the measurement period: M1284
OR
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND a dispensed medication for dementia during the measurement period or the year prior to the measurement period: M1291
OR
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND an advanced illness diagnosis during the measurement period or the year prior to the measurement period: M1292
Table: Dementia Exclusion Medications
Description
Prescription
Cholinesterase inhibitors
Donepezil Rivastigimine
Galantamine
Miscellaneous central nervous system agents
Memantine
Dementia combinations
Donepezil- memantine
Codes to identify Frailty (CPT, HCPCS or ICD-10-CM): 99504, 99509, E0100, E0105, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0163, E0165, E0167, E0168, E0170, E0171, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E0462, E0465, E0466, E0470, E0471, E0472, E0561, E0562, E1130, E1140, E1150, E1160, E1161, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E1296, E1297, E1298, G0162, G0299, G0300, G0493, G0494, S0271, S0311, S9123, S9124, T1000, T1001, T1002, T1003, T1004, T1005, T1019, T1020, T1021, T1022, T1030, T1031, L89.000, L89.001, L89.002, L89.003, L89.004, L89.006, L89.009, L89.010, L89.011, L89.012, L89.013, L89.014, L89.016, L89.019, L89.020, L89.021, L89.022, L89.023, L89.024, L89.026, L89.029, L89.100, L89.101, L89.102, L89.103, L89.104, L89.106, L89.109, L89.110, L89.111, L89.112, L89.113, L89.114, L89.116, L89.119, L89.120, L89.121, L89.122, L89.123, L89.124, L89.126, L89.129, L89.130, L89.131, L89.132, L89.133, L89.134, L89.136, L89.139, L89.140, L89.141, L89.142, L89.143, L89.144, L89.146, L89.149, L89.150, L89.151, L89.152, L89.153, L89.154, L89.156, L89.159, L89.200, L89.201, L89.202, L89.203, L89.204, L89.206, L89.209, L89.210, L89.211, L89.212, L89.213, L89.214, L89.216, L89.219, L89.220, L89.221, L89.222, L89.223, L89.224, L89.226, L89.229, L89.300, L89.301, L89.302, L89.303, L89.304, L89.306, L89.309, L89.310, L89.311, L89.312, L89.313, L89.314, L89.316, L89.319, L89.320, L89.321, L89.322, L89.323, L89.324, L89.326, L89.329, L89.40, L89.41, L89.42, L89.43, L89.44, L89.45, L89.46, L89.500, L89.501, L89.502, L89.503, L89.504, L89.506, L89.509, L89.510, L89.511, L89.512, L89.513, L89.514, L89.516, L89.519, L89.520, L89.521, L89.522, L89.523, L89.524, L89.526, L89.529, L89.600, L89.601, L89.602, L89.603, L89.604, L89.606, L89.609, L89.610, L89.611, L89.612, L89.613, L89.614, L89.616, L89.619, L89.620, L89.621, L89.622, L89.623, L89.624, L89.626, L89.629, L89.810, L89.811, L89.812, L89.813, L89.814, L89.816, L89.819, L89.890, L89.891, L89.892, L89.893, L89.894, L89.896, L89.899, L89.90, L89.91, L89.92, L89.93, L89.94, L89.95, L89.96, M62.50, M62.81, M62.84, R26.2, R26.89, R26.9, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64, W01.0XXA, W01.0XXD, W01.0XXS, W01.10XA, W01.10XD, W01.10XS, W01.110A, W01.110D, W01.110S, W01.111A, W01.111D, W01.111S, W01.118A, W01.118D, W01.118S, W01.119A, W01.119D, W01.119S, W01.190A, W01.190D, W01.190S, W01.198A, W01.198D, W01.198S, W06.XXXA, W06.XXXD, W06.XXXS, W07.XXXA, W07.XXXD, W07.XXXS, W08.XXXA, W08.XXXD, W08.XXXS, W10.0XXA, W10.0XXD, W10.0XXS, W10.1XXA, W10.1XXD, W10.1XXS, W10.2XXA, W10.2XXD, W10.2XXS, W10.8XXA, W10.8XXD, W10.8XXS, W10.9XXA, W10.9XXD, W10.9XXS, W18.00XA, W18.00XD, W18.00XS, W18.02XA, W18.02XD, W18.02XS, W18.09XA, W18.09XD, W18.09XS, W18.11XA, W18.11XD, W18.11XS, W18.12XA, W18.12XD, W18.12XS, W18.2XXA, W18.2XXD, W18.2XXS, W18.30XA, W18.30XD, W18.30XS, W18.31XA, W18.31XD, W18.31XS, W18.39XA, W18.39XD, W18.39XS, W19.XXXA, W19.XXXD, W19.XXXS, Y92.199, Z59.3, Z73.6, Z74.01, Z74.09, Z74.1, Z74.2, Z74.3, Z74.8, Z74.9, Z91.81, Z99.11, Z99.3, Z99.81, Z99.89
Codes to identify Advanced Illness (ICD-10-CM): A81.00, A81.01, A81.09, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C91.00, C91.02, C92.00, C92.02, C93.00, C93.02, C93.90, C93.92, C93.Z0, C93.Z2, C94.30, C94.32, F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F04, F10.27, F10.96, F10.97, G10, G12.21, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G35, I09.81, I11.0, I12.0, I13.0, I13.11, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J68.4, J84.10, J84.112, J84.170, J84.178, J96.10, J96.11, J96.12, J96.20, J96.21, J96.22, J96.90, J96.91, J96.92, J98.2, J98.3, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K74.00, K74.01, K74.02, K74.1, K74.2, K74.4, K74.5, K74.60, K74.69, N18.5, N18.6
Numerator (Submission Criteria 3):
Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period
Definition:
Mammography screening is defined by a bilateral screening (both breasts) of breast tissue. If only one breast is present, unilateral screening (one side) must be performed on the remaining breast.
Numerator Instructions:
This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.
Please note the measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.
NUMERATOR NOTE: Patient reported mammograms, when recorded in the medical record, are acceptable for meeting the numerator.
Numerator Options:
Performance Met: Screening, diagnostic, film digital or digital breast Tomosynthesis (3D) mammography results documented and reviewed (M1302)
OR
Performance Not Met: Screening, diagnostic, film, digital or digital breast Tomosynthesis (3D) mammography results were not documented and reviewed, reason not otherwise specified (M1285)
AND
SUBMISSION CRITERIA 4: ALL PATIENTS WHO WERE SCREENED FOR COLORECTAL CANCER SCREENING DENOMINATOR (SUBMISSION CRITERIA 4):
Patients 45-75 years of age with a visit during the measurement period
DENOMINATOR NOTE: To assess the age for exclusions, the patient’s age on the date of the encounter should be used.
*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients 45 to 75 years of age on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99386*, 99387*, 99396*, 99397*, 99421, 99422, 99423, 99457, G0438, G0439, G2250, G2251, G2252
AND NOT
DENOMINATOR EXCLUSIONS:
Patients with a diagnosis or past history of total colectomy or colorectal cancer: M1295
OR
Hospice services provided to patient any time during the measurement period: M1303
OR
Palliative care services provided to patient any time during the measurement period: M1309
OR
Patients age 66 or older in Institutional Special Needs Plans (SNP) or residing in long-term care with POS code 32, 33, 34, 54, or 56 for more than 90 consecutive days during the measurement period: M1284
OR
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND a dispensed medication for dementia during the measurement period or the year prior to the measurement period: M1291
OR
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND an advanced illness diagnosis during the measurement period or the year prior to the measurement period: M1292
Table: Dementia Exclusion Medications
Description
Prescription
Cholinesterase inhibitors
Donepezil Rivastigimine
Galantamine
Miscellaneous central nervous system agents
Memantine
Dementia combinations
Donepezil- memantine
Codes to identify Frailty (CPT, HCPCS or ICD-10-CM): 99504, 99509, E0100, E0105, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0163, E0165, E0167, E0168, E0170, E0171, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E0462, E0465, E0466, E0470, E0471, E0472, E0561, E0562, E1130, E1140, E1150, E1160, E1161, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E1296, E1297, E1298, G0162, G0299, G0300, G0493, G0494, S0271, S0311, S9123, S9124, T1000, T1001, T1002, T1003, T1004, T1005, T1019, T1020, T1021, T1022, T1030, T1031, L89.000, L89.001, L89.002, L89.003, L89.004, L89.006, L89.009, L89.010, L89.011, L89.012, L89.013, L89.014, L89.016, L89.019, L89.020, L89.021, L89.022, L89.023, L89.024, L89.026, L89.029, L89.100, L89.101, L89.102, L89.103, L89.104, L89.106, L89.109, L89.110, L89.111, L89.112, L89.113, L89.114, L89.116, L89.119, L89.120, L89.121, L89.122, L89.123, L89.124, L89.126, L89.129, L89.130, L89.131, L89.132, L89.133, L89.134, L89.136, L89.139, L89.140, L89.141, L89.142, L89.143, L89.144, L89.146, L89.149, L89.150, L89.151, L89.152, L89.153, L89.154, L89.156, L89.159, L89.200, L89.201, L89.202, L89.203, L89.204, L89.206, L89.209, L89.210, L89.211, L89.212, L89.213, L89.214, L89.216, L89.219, L89.220, L89.221, L89.222, L89.223, L89.224, L89.226, L89.229, L89.300, L89.301, L89.302, L89.303, L89.304, L89.306, L89.309, L89.310, L89.311, L89.312, L89.313, L89.314, L89.316, L89.319, L89.320, L89.321, L89.322, L89.323, L89.324, L89.326, L89.329, L89.40, L89.41, L89.42, L89.43, L89.44, L89.45, L89.46, L89.500, L89.501, L89.502, L89.503, L89.504, L89.506, L89.509, L89.510, L89.511, L89.512, L89.513, L89.514, L89.516, L89.519, L89.520, L89.521, L89.522, L89.523, L89.524, L89.526, L89.529, L89.600, L89.601, L89.602, L89.603, L89.604, L89.606, L89.609, L89.610, L89.611, L89.612, L89.613, L89.614, L89.616, L89.619, L89.620, L89.621, L89.622, L89.623, L89.624, L89.626, L89.629, L89.810, L89.811, L89.812, L89.813, L89.814, L89.816, L89.819, L89.890, L89.891, L89.892, L89.893, L89.894, L89.896, L89.899, L89.90, L89.91, L89.92, L89.93, L89.94, L89.95, L89.96, M62.50, M62.81, M62.84, R26.2, R26.89, R26.9, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64, W01.0XXA, W01.0XXD, W01.0XXS, W01.10XA, W01.10XD, W01.10XS, W01.110A, W01.110D, W01.110S, W01.111A, W01.111D, W01.111S, W01.118A, W01.118D, W01.118S, W01.119A, W01.119D, W01.119S, W01.190A, W01.190D, W01.190S, W01.198A, W01.198D, W01.198S, W06.XXXA, W06.XXXD, W06.XXXS, W07.XXXA, W07.XXXD, W07.XXXS, W08.XXXA, W08.XXXD, W08.XXXS, W10.0XXA, W10.0XXD, W10.0XXS, W10.1XXA, W10.1XXD, W10.1XXS, W10.2XXA, W10.2XXD, W10.2XXS, W10.8XXA, W10.8XXD, W10.8XXS, W10.9XXA, W10.9XXD, W10.9XXS, W18.00XA, W18.00XD, W18.00XS, W18.02XA, W18.02XD, W18.02XS, W18.09XA, W18.09XD, W18.09XS, W18.11XA, W18.11XD, W18.11XS, W18.12XA, W18.12XD, W18.12XS, W18.2XXA, W18.2XXD, W18.2XXS, W18.30XA, W18.30XD, W18.30XS, W18.31XA, W18.31XD, W18.31XS, W18.39XA, W18.39XD, W18.39XS, W19.XXXA, W19.XXXD, W19.XXXS, Y92.199, Z59.3, Z73.6, Z74.01, Z74.09, Z74.1, Z74.2, Z74.3, Z74.8, Z74.9, Z91.81, Z99.11, Z99.3, Z99.81, Z99.89
Codes to identify Advanced Illness (ICD-10-CM): A81.00, A81.01, A81.09, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C91.00, C91.02, C92.00, C92.02, C93.00, C93.02, C93.90, C93.92, C93.Z0, C93.Z2, C94.30, C94.32, F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F04, F10.27, F10.96, F10.97, G10, G12.21, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G35, I09.81, I11.0, I12.0, I13.0, I13.11, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, J43.0, J43.1, J43.2, J43.8, J43.9, J68.4, J84.10, J84.112, J84.170, J84.178, J96.10, J96.11, J96.12, J96.20, J96.21, J96.22, J96.90, J96.91, J96.92, J98.2, J98.3, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K74.00, K74.01, K74.02, K74.1, K74.2, K74.4, K74.5, K74.60, K74.69, N18.5, N18.6
Numerator (Submission Criteria 4):
Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:
- Fecal occult blood test (FOBT) during the measurement period
- Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period
- Colonoscopy during the measurement period or the nine years prior to the measurement period
- Computed tomography (CT) colonography during the measurement period or the four years prior to the measurement period
- Stool DNA (sDNA) with FIT test during the measurement period or the two years prior to the measurement period
NUMERATOR INSTRUCTIONS
Do not count digital rectal exam (DRE)-acquired fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.
Please note the measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.
NUMERATOR NOTE: Patient reported procedures and diagnostic studies, when recorded in the medical record, are acceptable for meeting the numerator.
Numerator Options:
Performance Met: Colorectal cancer screening results documented and reviewed (M1277)
OR
Performance Not Met: Colorectal cancer screening results were not documented and reviewed; reason not otherwise specified (M1315)
AND
SUBMISSION CRITERIA 5: ALL PATIENTS WHO WERE SCREENED FOR BODY MASS INDEX (BMI): SCREENING AND FOLLOW-UP PLAN
Denominator (Submission Criteria 5):
All patients aged 18 and older on the date of the encounter with at least one qualifying encounter during the measurement period
Definition:
Not Eligible for BMI Screening or Follow-Up Plan (Denominator Exclusions) – A patient is not eligible if one or more of the following reasons are documented:
- Patients receiving palliative or hospice care on the date of the current encounter or any time prior to the current encounter
- Patients who are pregnant on the date of the current encounter or any time during the measurement period prior to the current encounter
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥18 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99424, 99491, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447, G0473
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, FQ, 93, POS 02, POS 10
WITHOUT
Place of Service (POS): 12
AND NOT
DENOMINATOR EXCLUSIONS:
Documentation stating the patient has received or is currently receiving palliative or hospice care: M1307
OR
Documentation of patient pregnancy anytime during the measurement period prior to and including the current encounter: M1298
Numerator (Submission Criteria 5):
Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the encounter
Definitions:
Normal BMI Parameters – Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2
BMI – Body mass index (BMI) is a number calculated using the Quetelet index: weight divided by height squared (W/H2) and is commonly used to classify weight categories. “BMI” can be calculated using:
Metric Units: BMI = Weight (kg) / (Height (m) x Height (m))
OR
English Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703
Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI outside of normal parameters. A “follow-up” plan may include, but is not limited to:
- Documentation of education
- Referral (for example a Registered Dietitian Nutritionist (RDN), occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon) for lifestyle/behavioral therapy
- Pharmacological interventions
- Dietary supplements
- Exercise counseling
- Nutrition counselingPatients with a Documented Reason for Not Screening BMI (Denominator Exception) – Patient Reason:
- Patients who refuse measurement of height and/or weight on the date of the current encounter or any time during the measurement period prior to the current encounter.
OR
Medical Reason:
- Patients with a documented medical reason for not documenting BMI such as patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.Patients with a Documented Reason for Not Documenting a Follow-up Plan for BMI Outside Normal Parameters (Denominator Exception) –Medical Reason(s):
- Patients (e.g., elderly patients 65 years of age or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
Numerator Instructions:
- Height and Weight – An eligible clinician or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter. Self-reported values cannot be used.
- The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider.
- If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met.
- Follow-Up Plan – If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters”. (See Definitions for examples of follow-up plan treatments).
- Performance Met for M1293 & M1287
- If the provider documents a BMI and a follow-up plan for a BMI outside normal parameters at the current encounter OR
- If the patient has a documented BMI within the previous twelve months of the current encounter, the provider documents a follow-up plan for a BMI outside normal parameters at the current encounter OR
- If the patient has a documented BMI within the previous twelve months of the current encounter AND the patient has a documented follow-up plan for a BMI outside normal parameters within the previous twelve months of the current encounter
Numerator Options:
Performance Met: BMI is documented within normal parameters and no follow-up plan is required (M1296)
OR
Performance Met: BMI is documented above normal parameters and a follow-up plan is documented (M1293)
OR
Performance Met: BMI is documented below normal parameters and a follow-up plan is documented (M1287)
OR
Denominator Exception: BMI not documented due to medical reason OR patient refusal of height or weight measurement (M1297)
OR
Denominator Exception: BMI is documented as being outside of normal parameters, follow-up plan is not completed for documented medical reason (M1286)
OR
Performance Not Met: BMI not documented and no reason is given (M1314) OR
Performance Not Met: BMI documented outside normal parameters, no follow-up plan documented, no reason given (M1276)
AND
SUBMISSION CRITERIA 6: ALL PATIENTS WHO WERE SCREENED FOR TOBACCO USE: SCREENING AND CESSATION INTERVENTION
Submission Criteria 6 includes 3 performance rates: Only 6b is required for reporting:
- Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period
- Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period
- Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user
The denominator of Submission Criteria 6b is a subset of the resulting numerator for Submission Criteria 6a, as Submission Criteria 6b is limited to assessing if patients identified as tobacco users received an appropriate tobacco cessation intervention. For all patients, Submission Criteria 6a and 6c are applicable, but Submission Criteria 6b will only be applicable for those patients who are identified as tobacco users.
By separating this measure into various submission criteria, the MIPS eligible professional or MIPS eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 6b is used for the composite performance rate and is the only performance rate required for Submission Criteria 6 for the purposes of reporting this measure.
Denominator (Submission Criteria 6 – Performance Rate A):
All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 12 years on date of encounter
AND
At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, G0270, G0271, G2250, G2251, G2252
OR
At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Hospice services provided to patient any time during the measurement period: M1303
Numerator (Submission Criteria 6 – Performance Rate A):
Patients who were screened for tobacco use at least once within the measurement period
Definition:
Tobacco Use – use of any tobacco product.
The 2021 USPSTF recommendation references the US Food and Drug Administration definition of tobacco which includes “any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems.”
The 2021 USPSTF recommendation describes smoking as generally referring to “the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes.”
The 2021 USPSTF recommendation describes vaping as “the inhaling and exhaling of aerosols produced by e- cigarettes.” In addition, it states, “vaping products (i.e., e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape. While the 2015 USPSTF recommendation statement used the term ‘electronic nicotine delivery systems’ or ‘ENDS,’ the USPSTF recognizes that the field has shifted to using the term ‘e-cigarettes’ (or ‘e-cigs’) and uses the term e- cigarettes in the current recommendation statement. e-Cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or ‘vapor’) that is inhaled (‘vaped’) by users.”
NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.
In the event that a patient is screened for tobacco use and tobacco status is unknown, submit M1312.
Numerator Options:
Performance Met: Patient screened for tobacco use AND identified as a tobacco user (M1283)
OR
Performance Met: Patient screened for tobacco use AND identified as a tobacco non-user (M1282)
OR
Performance Not Met: Patient not screened for tobacco use (M1312)
Denominator (Submission Criteria 6 – Performance Rate B):
All patients aged 12 years and older seen for at least two visits or at least one preventive visit who were screened for tobacco use during the measurement period and identified as a tobacco user
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 12 years on date of encounter
AND
All eligible instances when M1283 is submitted for Performance Met (patient screened for tobacco use and identified as a tobacco user) in the numerator of Submission Criteria 6 – Performance Rate A
AND
At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, G0270, G0271, G2250, G2251, G2252
OR
At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Hospice services provided to patient any time during the measurement period: M1303
Numerator (Submission Criteria 6 – Performance Rate B):
Patients who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period
Definition:
Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy.
Note: Concepts aligned with brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) are included in the numerator. Other concepts such as written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify for the numerator. Counseling also may be of longer duration or be performed more frequently, as evidence shows that higher-intensity interventions are associated with higher tobacco cessation rates (U.S. Preventive Services Task Force, 2021).
NUMERATOR NOTE: If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.
This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, submit G-code M1301.
Numerator Options:
Performance Met: Patient identified as a tobacco user received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy) (M1301)
OR
Performance Not Met: Patient identified as tobacco user did not receive tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy) (M1289)
Denominator (Submission Criteria 6 – Performance Rate C):
All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 12 years on date of encounter
AND
At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, G0270, G0271, G2250, G2251, G2252
OR
At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Hospice services provided to patient any time during the measurement period: M1303
Numerator (Submission Criteria 6 – Performance Rate C):
Patients who were screened for tobacco use at least once within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user
Definitions:
Tobacco Use – use of any tobacco product.
The 2021 USPSTF recommendation references the US Food and Drug Administration definition of tobacco which includes “any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems.”
The 2021 USPSTF recommendation describes smoking as generally referring to “the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes.”
The 2021 USPSTF recommendation describes vaping as “the inhaling and exhaling of aerosols produced by e- cigarettes.” In addition, it states, “vaping products (i.e., e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape. While the 2015 USPSTF recommendation statement used the term ‘electronic nicotine delivery systems’ or ‘ENDS,’ the USPSTF recognizes that the field has shifted to using the term ‘e-cigarettes’ (or ‘e-cigs’) and uses the term e- cigarettes in the current recommendation statement. e-Cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or ‘vapor’) that is inhaled (‘vaped’) by users.”
Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy. Note: Concepts aligned with brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) are included in the numerator. Other concepts such as written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify for the numerator. Counseling also may be of longer duration or be performed more frequently, as evidence shows that higher-intensity interventions are associated with higher tobacco cessation rates (U.S. Preventive Services Task Force, 2021).
NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.
In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation intervention during the measurement period or in the six months prior to the measurement period or if tobacco status is unknown, submit M1313.
If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.
This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, submit M1310.
Numerator Options:
Performance Met: Patient screened for tobacco use AND received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling, pharmacotherapy, or both), if identified as a tobacco user (M1310)
OR
Performance Met: Current tobacco non-user (M1316)
OR
Performance Not Met: Tobacco screening not performed OR tobacco cessation intervention not provided during the measurement period or in the six months prior to the measurement period (M1313)
AND
SUBMISSION CRITERIA 7: ALL PATIENTS WHO WERE SCREENED FOR HIGH BLOOD PRESSURE AND FOLLOW-UP DOCUMENTED
Denominator (Submission Criteria 7):
All patient visits for patients aged 18 years and older at the beginning of the performance period
Definition:
Not Eligible for High Blood Pressure Screening (Denominator Exclusion) –
- Patient has an active diagnosis of hypertension prior to the current encounter
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years at the beginning of the performance period
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92622, 92625, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99424, 99491, D3921, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0270, G0402, G0438, G0439
- WITHOUTTelehealth Modifier (including but not limited to): GQ, GT, FQ, 93, POS 02, POS 10
AND NOT
DENOMINATOR EXCLUSION:
Patient not eligible due to active diagnosis of hypertension: M1290
Numerator (Submission Criteria 7):
Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive
Definitions:
Blood Pressure (BP) Classification – BP is defined by four (4) BP reading classifications: Normal, Elevated, First Hypertensive, and Second Hypertensive Readings
- Normal BP: Systolic BP (SBP) < 120 mmHg AND Diastolic BP (DBP) < 80 mmHg
- Elevated BP: SBP of 120-129 mmHg AND DBP < 80 mmHg
- First Hypertensive Reading: SBP of >=130 mmHg OR DBP of >= 80 mmHg without a previous SBP of ≥ 130 mmHg OR DBP of >= 80 mmHg during the 12 months prior to the encounter
- Second Hypertensive Reading: Requires a SBP >= 130 mmHg OR DBP >= 80 mmHg during the current encounter AND a most recent BP reading within the last 12 months SBP >= 130 mmHg OR DBP >= 80 mmHgRecommended BP Follow-Up – The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults from the American College of Cardiology and American Heart Association (2017 Guideline) recommends BP screening and thresholds as defined under Blood Pressure Classifications and recommends interventions based on the current BP reading as listed in the “RecommendedBlood Pressure Follow- Up” Table below. The time periods for follow-up actions specified for the elevated and the second hypertensive (130-139 DBP OR 80-89 SBP) BP classifications slightly differ from time periods given in the 2017 Guideline. This allows for clinician discretion due to patient condition and stability of the measure specification over time.
Recommended Nonpharmacologic Interventions (Lifestyle Modifications) – The 2017 Guideline outlines nonpharmacologic interventions which must include one or more of the following as indicated:
- Weight Reduction
- A “heart-healthy diet”, such as Dietary Approaches to Stop Hypertension (DASH) Eating Plan
- Dietary Sodium Restriction
- Increased Physical Activity
- Moderation in alcohol consumptionRecommended Blood Pressure Follow-Up Table
BP Classification
Systolic BP mmHg
Diastolic BP mmHg
Recommended Follow-Up
(must include all indicated actions for each BP Classification)
Normal
BP Reading
< 120
AND < 80
No Follow-Up required
Elevated BP Reading
120-129
AND < 80
Rescreen BP within 6 months AND
recommended nonpharmacologic interventions
OR
Referral to Alternate/Primary Care Provider
First Hypertensive BP Reading
>= 130
OR >= 80
Rescreen BP within 4 weeks AND recommended nonpharmacologic interventions
OR
Referral to Alternate/Primary Care Provider
Second Hypertensive BP Reading
130-139
and NOT >= 140
OR 80-89
and NOT >= 90
Recommended nonpharmacologic intervention AND reassessment within 6 months AND an order for laboratory test or ECG for hypertension
OR
Referral to Alternate/Primary Care Provider
Second Hypertensive BP Reading
>= 140
OR >= 90
Recommended nonpharmacologic intervention AND BP-lowering medication AND reassessment within 4 weeks AND an order for laboratory test or ECG for hypertension
OR
Referral to Alternate/Primary Care Provider
Patients with a Documented Reason for not Screening or no Follow-Up Plan for High Blood Pressure (Denominator Exceptions) –
- Documentation of medical reason(s) for not screening for high blood pressure (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status).
- Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient BP is elevated or hypertensive (e.g., patient refuses).
NUMERATOR NOTE: Although the recommended screening interval for a normal BP reading is every year, to meet the intent of this measure, BP screening and follow-up must be performed at every patient visit. For patients with Normal blood pressure, a follow-up plan is not required (M1294). Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: Normal blood pressure reading documented, follow-up not required (M1294)
OR
Performance Met: Elevated or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented (M1278)
OR
Denominator Exception: Documented reason for not screening or recommending a follow-up for high blood pressure (M1288)
OR
Performance Not Met: Blood pressure reading not documented, reason not given (M1281)
OR
Performance Not Met: Elevated or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given (M1279)
Stay updated with the latest news regarding MACRA and MIPS
The Healthmonix Advisor is a free news source that connects you to the latest in the value-based care industry!