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MVP: Promoting Wellness

Most applicable medical specialties: Preventive medicine, internal medicine, family medicine, geriatrics

The Promoting Wellness MVP focuses on the clinical theme of promoting quality care for patients in order to reduce the risk of diseases, disabilities, and death.


To fulfill quality requirements:

  1. You must select 4 quality measures from the list below
    (exception for clinicians in a small practice – see # 3 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. If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don’t need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
  4. You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2023 – December 31, 2023).

    TIP: For small practices (participating at the individual, group or subgroup level) reporting Medicare Part B claims measures: To meet data completeness requirements, you’ll need to start reporting the Medicare Part B claims measures in your selected MVP in January 2023, prior to the MVP registration period.

    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.
039Screening for Osteoporosis for
Women Aged 65-85 Years of Age
112Breast Cancer ScreeningDetails
113Colorectal Cancer ScreeningDetails
128Preventive Care and Screening: Body Mass
Index (BMI) Screening and Follow-Up Plan
134Preventive Care and Screening: Screening
for Depression and Follow-Up Plan
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionDetails
309Cervical Cancer ScreeningDetails
310Chlamydia Screening for WomenDetails
321CAHPS for MIPS Clinician/Group SurveyDetails
400One-Time Screening for
Hepatitis C Virus (HCV) for all Patients
431Preventive Care and Screening: Unhealthy
Alcohol Use: Screening & Brief Counseling
475HIV ScreeningDetails
483*Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)Details
493Adult Immunization StatusDetails

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_AHE_3Promote Use of Patient-Reported
Outcome Tools
IA_AHE_12Practice Improvements that Engage Community Resources to Address Drivers of Health
IA_BE_4Engagement of patients through implementation of improvements in patient portal
IA_BE_6Regularly Assess Patient Experience of Care
and Follow Up on Findings
IA_BE_12Use evidence-based decision aids to support shared decision-making.
IA_BMH_9Unhealthy Alcohol Use for Patients with
Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients
IA_CC_2Implementation of improvements that contribute to more timely communication of test results
IA_CC_13Practice Improvements to Align with
OpenNotes Principles
IA_EPA_1Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record
IA_PCMHElectronic submission of Patient Centered Medical Home accreditation
IA_PM_11Regular review practices in place on targeted patient population needs
IA_PM_13Chronic Care and Preventative Care Management for Empaneled Patients
IA_PM_16Implementation of medication
management practice improvements
IA_PSPA_19Implementation of formal quality improvement methods, practice changes, or other practice improvement processes


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.
TPCC_1Total Per Capita Cost (TPCC)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.

Clinician Types for Automatic Reweighting:

  • Physical therapist (PT)
  • Occupational therapist (OT)
  • Qualified speech-language pathologist (SLP)
  • Qualified audiologist (AuD)
  • Clinical psychologist
  • Registered dietitian (RD) or nutrition professional
  • 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_ONCDIR_1ONC Direct Review  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 (2022)Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) GroupsDetails
484 (2022)Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic ConditionsDetails
*2023 versions will be available once updated from CMS.