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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.


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, 2024 – December 31, 2024).

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

Improvement Activities

You must report 1 of the following 3 options:

1. Two medium weighted improvement activities from the list below, or

2. One high weighted improvement activity from the list below, or

3. The IA_PCMH activity (participation in a certified or recognized patient-centered medical home
or a comparable specialty practice).

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_EPA_1Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record
 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


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.
MSPB_1Medicare Spending Per
Beneficiary (MSPB) Clinician

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.

Clinician Types for Automatic Reweighting:

  • Clinical social worker

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.

PI_EP_2Query of the Prescription Drug Monitoring Program (PDMP)
PI_HEI_1Support Electronic Referral Loops By Sending Health Information
PI_HEI_4Support Electronic Referral Loops By Receiving and Reconciling Health Information
PI_HEI_5Health Information Exchange (HIE) Bi-Directional Exchange
PI_HEI_6Enabling Exchange Under TEFCA
PI_PEA_1Provide Patients Electronic Access to Their Health Information
PI_PHCDRR_1Immunization Registry Reporting
PI_PHCDRR_2Syndromic Surveillance Reporting
PI_PHCDRR_3Electronic Case Reporting
PI_PHCDRR_4Public Health Registry Reporting
PI_PHCDRR_5Clinical Data Registry Reporting
PI_PPHI_1Security Risk Analysis
PI_PPHI_2High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides
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_ONCDIR_1ONC Direct Review  Attestation
PI_ONCACB_1ONC-ACB Surveillance Attestation

Foundational Layer – Population Health

You must select 1 population health measure at the time of MVP registration.

  • You don’t have to submit any data for this measure, CMS will calculate the 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.
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