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MVP: Patient Safety and Support of Positive Experiences with Anesthesia

Most applicable medical specialty: Anesthesiology

The Patient Safety and Support of Positive Experiences with Anesthesia MVP focuses on increasing quality of anesthesia care, improving postoperative outcomes, promoting patient safety, and enhancing satisfaction for patients receiving anesthesia. The measures are used for a variety of surgical procedures that anesthesiologists deliver care for, and are broadly applicable to anesthesiologists practicing within ambulatory, outpatient, and inpatient hospital settings.

Quality

To fulfill quality requirements:

  1. You must select 4 quality measures from the list below
  2. At least 1 measure must be an outcome measure
    • If no outcome measures are available, you may report a high priority measure.
  3. You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2025 – December 31, 2025).

TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don’t meet case minimum or data completeness criteria will earn zero points.

IDTitleTitle
404Anesthesiology Smoking AbstinenceDetails
424Perioperative Temperature ManagementDetails
430Prevention of Post-Operative Nausea and
Vomiting (PONV) – Combination Therapy
Details
463Prevention of Post-Operative Vomiting
(POV) – Combination Therapy (Pediatrics)
Details
477Multimodal Pain ManagementDetails
487Screening for Social Drivers of HealthDetails
ABG44Low Flow Inhalational General AnesthesiaNot supported by MIPSpro*
AQI48*Patient-Reported
Experience with Anesthesia
Not supported by MIPSpro*
EPREOP31Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical CasesNot supported by MIPSpro*

Improvement Activities


To fulfill improvement activity requirements:

1. You must report 1 improvement activity from the list below.

Beginning in 2025, improvement activities don’t have assigned weights.

 Download 2025 Improvement Activities Inventory (ZIP)

IDTitle
IA_BE_6Regularly Assess Patient Experience of Care and Follow
IA_BE_22Improved Practices that Engage Patients Pre-Visit
IA_BMH_2Tobacco use
IA_CC_2Implementation of improvements that contribute to more timely communication of test results
IA_CC_15PSH Care Coordination
IA_CC_19Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.
IA_PM_26Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B
 IA_MVPPractice-Wide Quality Improvement in MIPS Value Pathways
 IA_PCMHElectronic submission of Patient Centered Medical Home accreditation
IA_PSPA_1Participation in an AHRQ-listed patient safety organization
IA_PSPA_7Use of QCDR data for ongoing practice assessment and improvements
IA_PSPA_16Use of decision support and standardized treatment protocols

Cost

Important information to consider:

  1. You don’t have to submit any data for this performance category. We’ll use Medicare claims data to calculate your cost measure performance.
    • You don’t select cost measures during MVP registration. CMS will calculate your performance on all the cost measures included in the MVP based on available Medicare claims data.
  2. You’ll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.
IDTitleSpecs
MSPB_1Medicare Spending Per
Beneficiary (MSPB) Clinician
Details

Foundational Layer – Promoting Interoperability

To fulfill Promoting Interoperability requirements:

  1. Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren’t required.
    • If you’re reporting as a subgroup, you’ll submit your affiliated group’s data for the Promoting Interoperability performance category.
  2. Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.

Special Status for Automatic Reweighting:

  • Ambulatory Surgical Center (ASC)-based
  • Hospital-based
  • Non-patient facing
  • Small practice

Promoting Interoperability Performance Category Hardship Exception Qualifications:

  • Decertified EHR technology
  • Insufficient internet connectivity
  • Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
  • Lack control over availability of CEHRT (Certified Electronic Health Record Technology)

Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.

IDTitle
PI_EP_1e-Prescribing
PI_EP_2Query of the Prescription Drug
Monitoring Program (PDMP)
PI_EP_2_EX_1Query of the Prescription Drug Monitoring Program (PDMP)
PI_EP_2_EX_2Query of the Prescription Drug Monitoring Program (PDMP) Exclusion
PI_HIE_1Support Electronic Referral Loops By Sending Health Information
PI_HIE_4Support Electronic Referral Loops By Receiving and Reconciling Health Information
PI_HIE_5Health Information Exchange (HIE)
Bi-Directional Exchange
PI_HIE_6Enabling Exchange Under TEFCA
PI_INFBLO_1Actions to Limit or Restrict the Compatibility of CEHRT
 PI_LVITC_2Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
 PI_LVOTC_1Support Electronic Referral Loops By Sending Health Information Exclusion
PI_LVPP_1e-Prescribing Exclusion
PI_ONCACB_1ONC-ACB Surveillance Attestation
PI_ONCDIR_1ONC Direct Review Attestation
PI_PEA_1Provide Patients Electronic Access to
Their Health Information
PI_PHCDRR_1Immunization Registry Reporting
PI_PHCDRR_1_EX_1Immunization Registry Reporting Exclusion
PI_PHCDRR_1_EX_2Immunization Registry Reporting Exclusion
PI_PHCDRR_1_EX_3Immunization Registry Reporting Exclusion
PI_PHCDRR_1_PREImmunization Registry Reporting Active Engagement Level 1
PI_PHCDRR_1_PRODImmunization Registry Reporting Active Engagement Level 2
PI_PHCDRR_2Syndromic Surveillance Reporting
PI_PHCDRR_2_PRESyndromic Surveillance Reporting Active Engagement Level 1
PI_PHCDRR_2_PRODSyndromic Surveillance Reporting Active Engagement Level 2
PI_PHCDRR_3Electronic Case Reporting
PI_PHCDRR_3_EX_1Electronic Case Reporting Exclusion
PI_PHCDRR_3_EX_2Electronic Case Reporting Exclusion
PI_PHCDRR_3_EX_3Electronic Case Reporting Exclusion
PI_PHCDRR_3_PREElectronic Case Reporting Active Engagement Level 1
PI_PHCDRR_3_PRODElectronic Case Reporting Active Engagement Level 2
PI_PHCDRR_4Public Health Registry Reporting
PI_PHCDRR_4_PREPublic Health Registry Reporting Active Engagement Level 1
PI_PHCDRR_4_PRODPublic Health Registry Reporting Active Engagement Level 2
PI_PHCDRR_5Clinical Data Registry Reporting
PI_PHCDRR_5_PREClinical Data Registry Reporting Active Engagement Level 1
PI_PHCDRR_5_PRODClinical Data Registry Reporting Active Engagement Level 2
PI_PPHI_1Security Risk Analysis
PI_PPHI_2SAFER Guides High Priority Practices Guide

Foundational Layer – Population Health

  • You won’t be required to select a population health measure during registration. This is different from the 2024 MVP registration process requiring you to select a population health measure. You don’t have to submit any data for this measure, we will calculate all available population health measures for you, using administrative claims data.
  • This measure will be excluded from scoring if the measure doesn’t have a benchmark or meet the case minimum.
  • Population health isn’t a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.
  • Subgroups will be evaluated at the affiliated group level.
IDTitleSpecs
479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) GroupsDetails
484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic ConditionsDetails

Begin your MVP journey today