MVP: Patient Safety and Support of Positive Experiences with Anesthesia

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.

ID	Title	Title
404	Anesthesiology Smoking Abstinence	Details
424	Perioperative Temperature Management	Details
430	Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy	Details
463	Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)	Details
477	Multimodal Pain Management	Details
487	Screening for Social Drivers of Health	Details
ABG44	Low Flow Inhalational General Anesthesia	Not supported by MIPSpro*
AQI48*	Patient-Reported Experience with Anesthesia	Not supported by MIPSpro*
EPREOP31	Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases	Not supported by MIPSpro*

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).

ID	Title
IA_BE_6	Regularly Assess Patient Experience of Care and Follow
IA_BE_22	Improved Practices that Engage Patients Pre-Visit
IA_BMH_2	Tobacco use
IA_CC_2	Implementation of improvements that contribute to more timely communication of test results
IA_CC_15	PSH Care Coordination
IA_CC_19	Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.
IA_EPA_1	Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record
IA_MVP	Practice-Wide Quality Improvement in MIPS Value Pathways
IA_PCMH	Electronic submission of Patient Centered Medical Home accreditation
IA_PSPA_1	Participation in an AHRQ-listed patient safety organization
IA_PSPA_7	Use of QCDR data for ongoing practice assessment and improvements
IA_PSPA_16	Use 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.

ID	Title	Specs
MSPB_1	Medicare Spending Per Beneficiary (MSPB) Clinician	Details

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.

ID	Title
PI_EP_1	e-prescribing
PI_EP_2	Query of the Prescription Drug Monitoring Program (PDMP)
PI_HEI_1	Support Electronic Referral Loops By Sending Health Information
PI_HEI_4	Support Electronic Referral Loops By Receiving and Reconciling Health Information
PI_HEI_5	Health Information Exchange (HIE) Bi-Directional Exchange
PI_HEI_6	Enabling Exchange Under TEFCA
PI_PEA_1	Provide Patients Electronic Access to Their Health Information
PI_PHCDRR_1	Immunization Registry Reporting
PI_PHCDRR_2	Syndromic Surveillance Reporting
PI_PHCDRR_3	Electronic Case Reporting
PI_PHCDRR_4	Public Health Registry Reporting
PI_PHCDRR_5	Clinical Data Registry Reporting
PI_PPHI_1	Security Risk Analysis
PI_PPHI_2	High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides
PI_INFBLO_1	Actions to Limit or Restrict the Compatibility of CEHRT
PI_LVITC_2	Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_LVOTC_1	Support Electronic Referral Loops By Sending Health Information Exclusion
PI_LVPP_1	e-Prescribing Exclusion
PI_ONCDIR_1	ONC Direct Review  Attestation
PI_ONCACB_1	ONC-ACB Surveillance Attestation

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.

ID	Title	Specs
479	Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups	Details
484	Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions	Details