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MVP: Rehabilitative Support for Musculoskeletal Care

Most applicable medical specialty: Chiropractic medicine, physiatry, physical therapy, occupational therapy

The Rehabilitative Support for Musculoskeletal Care MVP focuses on the clinical theme of promoting quality care for patients.

Quality


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, 2024- December 31, 2024).

    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 2024, 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.
IDTitleSpecs
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanDetails
155Falls: Plan of CareDetails
217Functional Status Change for Patients with Knee ImpairmentsDetails
218Functional Status Change for Patients with Hip Impairments Details
219Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsDetails
220Functional Status Change for Patients with Low Back ImpairmentsDetails
221Functional Status Change for Patients with Shoulder ImpairmentsDetails
222Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsDetails
478Functional Status Change for Patients with Neck ImpairmentsDetails

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).

IDTitle
IA_AHE_12Practice Improvements that Engage Community Resources to Address Drivers of Health
IA_AHE_3Promote Use of Patient-Reported Outcome Tools
IA_AHE_6Provide Education Opportunities for New Clinicians
IA_AHE_9Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
IA_BE_6Regularly Assess Patient Experience of Care and Follow Up on Findings
IA_BMH_12Promoting Clinician Well-Being
IA_BMH_15Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults
IA_CC_1Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
IA_CC_12Care coordination agreements that promote improvements in patient tracking across settings
IA_CC_8Implementation of documentation improvements for practice/process improvements
IA_EPA_1Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record
IA_BMH_7Implementation of Integrated Patient Centered Behavioral Health Model
IA_EPA_2Use of telehealth services that expand practice access
IA_EPA_3Collection and use of patient experience and satisfaction data on access
IA_MVPPractice-Wide Quality Improvement in MIPS Value Pathways
IA_PCMHElectronic submission of Patient Centered Medical Home accreditation
IA_PSPA_16Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.
IA_PSPA_21Implementation of fall screening and assessment programs

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
COST_LBP_1Low Back PainDetails

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.

IDTitle
PI_EP_1e-prescribing
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_ONCACB_1ONC-ACB Surveillance Attestation
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.
IDTitleSpecs
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 ConditionsDetails

Begin your MVP journey today