Most applicable medical specialty: Anesthesiology
The Patient Safety and Support of Positive Experiences with Anesthesia MVP focuses on increasing quality of anesthesia care, improving postoperative outcomes, promoting patient safety, and enhancing satisfaction for patients receiving anesthesia. The measures are used for a variety of surgical procedures that anesthesiologists deliver care for, and are broadly applicable to anesthesiologists practicing within ambulatory, outpatient, and inpatient hospital settings.
Quality
To fulfill quality requirements:
- You must select 4 quality measures from the list below
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- 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: 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: G0059)
ID
Title
Specs
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: G0059)
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_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
Cost
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
case minimum.
Cost Measures (MVP ID: G0059)
ID
Title
Specs
Foundational Layer - Promoting Interoperability
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
- 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)
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_ONCDIR_1
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)
ID
Title
Specs
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.
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