MVP: Optimizing Chronic Disease Management
Most applicable medical specialties: Cardiology, Internal Medicine, Family Medicine
The Optimizing Chronic Disease Management MVP focuses on the clinical theme of providing fundamental treatment and management of chronic disease such as diabetes, coronary artery disease, chronic obstructive disease, and major adult depression.
To fulfill quality requirements:
- You must select 4 quality measures from the list below
(exception for clinicians in a small practice - see # 3 below)
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- 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.
- 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).
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: G0056)
CAHPS for MIPS
Clinician /Group Survey
*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).
Improvement Activities (MVP ID: G0056)
Promote Use of Patient-Reported
Practice Improvements that Engage Community Resources to Address Drivers of Health
Engagement of patients through implementation of improvements in patient portal
Promote Self-management in Usual Care
Improved Practices that Engage
Implementation of improvements that contribute to more timely communication of test results
Care coordination agreements that promote improvements in patient tracking across settings
Practice Improvements to Align with
Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
Electronic submission of Patient Centered Medical Home accreditation
Chronic Care and Preventative Care Management for Empaneled Patients
Implementation of methodologies for improvements in longitudinal care management for high risk patients
Administration of the AHRQ Survey of Patient Safety Culture
Use of QCDR data for ongoing practice assessment and improvements
Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
Important information to consider:
- 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.)
- You'll only be scored on the cost measures in this MVP for which you meet or exceed the established
Cost Measures (MVP ID: G0056)
To fulfill Promoting Interoperability requirements:
- 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.
- 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
- 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)
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
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)
Begin your MVP journey today.