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MVP: Optimal Care for Kidney Health 

Most applicable medical specialty: Nephrology

The Optimal Care for Kidney Health MVP focuses on the clinical theme of providing fundamental treatment
and management of costly clinical conditions that contribute to, or may result from, kidney disease.


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.
    • This MVP includes an outcome measure calculated by CMS through administrative claims. If you
      select it as 1 of your 4 required quality measures, this must be included in your MVP registration.

      TIP: Before selecting an outcomes-based administrative claims measure, make sure your patient population will allow you to meet the case minimum; if not, you'll receive 0 achievement points for the measure. If you're unsure if you’ll meet the case minimum, you may want to report an additional outcome 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.

Quality Measures (MVP ID: M0002)





Diabetes: Hemoglobin A1c
(HbA1c) Poor Control (>9%)


Advance Care Plan



Preventive Care and Screening:
Influenza Immunization


Pneumococcal Vaccination
Status for Older Adults


Documentation of Current
Medications in the Medical Record


Controlling High Blood Pressure


Hemodialysis Vascular Access: Practitioner
Level Long-term Catheter Rate

*Not supported by MIPSpro


Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy

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).

Improvement Activities (MVP ID: M0002)




Promote Use of Patient-Reported
Outcome Tools


Engagement of patients through implementation of improvements in patient portal


Regularly Assess Patient Experience of
Care and Follow Up on Findings


Engage Patients and Families to Guide Improvement in the System of Care


Engagement of Patients, Family, and
Caregivers in Developing a Plan of Care


Promote Self-management in Usual Care


Implementation of improvements that contribute to more timely communication of test results


Practice Improvements to Align
with OpenNotes Principles


Electronic submission of Patient
Centered Medical Home accreditation


Regular review practices in place on
targeted patient population needs


Implementation of methodologies for improvements in longitudinal care management for high risk patients


Implementation of medication
management practice improvements


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.

Cost Measures (MVP ID: M0002)





Acute Kidney Injury Requiring
New Inpatient Dialysis


Total Per Capita Cost (TPCC)

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.

Promoting Interoperability Measures (All MVPs)






Query of the Prescription Drug
Monitoring Program (PDMP)


Support Electronic Referral Loops By Sending Health Information


Support Electronic Referral Loops By Receiving and Reconciling Health Information


Health Information Exchange (HIE)
Bi-Directional Exchange


Enabling Exchange Under TEFCA


Provide Patients Electronic Access to
Their Health Information


Immunization Registry Reporting


Syndromic Surveillance Reporting


Electronic Case Reporting


Public Health Registry Reporting


Clinical Data Registry Reporting


Security Risk Analysis


High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides


Actions to Limit or Restrict the
Compatibility of CEHRT


ONC 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.

Improvement Activities (All MVPs)




479 (2022)

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups

484 (2022)

Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

*2023 versions will be available once updated from CMS.

Looking for a different MVP? Head back to our complete listing of MVPs.

Begin your MVP journey today.