How to Select MIPS Quality Measures
Step 1 : Select At Least 1 Outcome Measure
For the MIPS Quality Performance Category, you must report at least one outcome measure. If no outcome measures are applicable to your patient population, then you must select at least one high-priority measure (see Step 2). The outcome measures you report count towards the six measure requirement for the Quality Performance Category. Reporting additional outcome measures beyond the required one will award two (2) bonus points to your Quality Performance Category Score.
Step 2 : Select Applicable High-Priority Measures
If you were able to select an outcome measure in Step 1, this step is optional. Non-outcome high-priority measures are worth one (1) bonus point for the Quality Performance Category. This makes it a smart idea to include as many outcome and/or high-priority measures as possible in your six Quality Performance Category Measures.
Step 3 : Make Sure You Have 6 Measures Selected
If you have not yet selected six measures and are aiming for a positive MIPS Payment Adjustment, select from the other recommended measures. If you report over six measures, CMS will calculate your MIPS Quality Performance Score using your top performing quality measures.
Recommended Quality Measures
| Quality Id | Measure Name | High Priority | Measure Type | Measure Description | Details |
|---|---|---|---|---|---|
| 005 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | no | Process | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge | Read More |
| 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | yes | Intermediate Outcome | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period | Read More |
| 052 | Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | no | Process | Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator | Read More |
| 051 | Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | no | Process | Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented | Read More |
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | yes | Process | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Read More |
| 048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | no | Process | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Read More |
| 047 | Advance Care Plan | yes | Process | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Read More |
| 046 | Medication Reconciliation Post-Discharge | yes | Process | The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record This measure is reported as three rates stratified by age group: • Submission Criteria 1: 18-64 years of age • Submission Criteria 2: 65 years and older • Total Rate: All patients 18 years of age and older | Read More |
| 039 | Screening for Osteoporosis for Women Aged 65-85 Years of Age | no | Process | Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis | Read More |
| 008 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | no | Process | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge | Read More |
| 007 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | no | Process | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy | Read More |
| 006 | Coronary Artery Disease (CAD): Antiplatelet Therapy | no | Process | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel | Read More |
| 117 | Diabetes: Eye Exam | no | Process | Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period | Read More |
| 116 | Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | yes | Process | The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription | Read More |
| 113 | Colorectal Cancer Screening | no | Process | Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer | Read More |
| 112 | Breast Cancer Screening | no | Process | Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer | Read More |
| 111 | Pneumococcal Vaccination Status for Older Adults | no | Process | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | Read More |
| 109 | Osteoarthritis (OA): Function and Pain Assessment | yes | Process | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain | Read More |
| 093 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | yes | Process | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Read More |
| 091 | Acute Otitis Externa (AOE): Topical Therapy | yes | Process | Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations | Read More |
| 066 | Appropriate Testing for Children with Pharyngitis | yes | Process | Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode | Read More |
| 065 | Appropriate Treatment for Children with Upper Respiratory Infection (URI) | yes | Process | Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode | Read More |
| 110 | Preventive Care and Screening: Influenza Immunization | no | Process | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | Read More |
| 154 | Falls: Risk Assessment | yes | Process | Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months | Read More |
| 155 | Falls: Plan of Care | yes | Process | Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months | Read More |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | no | Process | Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen | Read More |
| 131 | Pain Assessment and Follow-Up | yes | Process | Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present | Read More |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | no | Process | Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2 | Read More |
| 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | no | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing | Read More |
| 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | no | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months | Read More |
| 119 | Diabetes: Medical Attention for Nephropathy | no | Process | The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period | Read More |
| 130 | Documentation of Current Medications in the Medical Record | yes | Process | Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration | Read More |
| 205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | no | Process | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection | Read More |
| 185 | Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | yes | Process | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy | Read More |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | yes | Process | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen | Read More |
| 178 | Rheumatoid Arthritis (RA): Functional Status Assessment | no | Process | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months | Read More |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | no | Process | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user | Read More |
| 236 | Controlling High Blood Pressure | yes | Intermediate Outcome | Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period | Read More |
| 238 | Use of High-Risk Medications in the Elderly | yes | Process | Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication 2) Percentage of patients who were ordered at least two of the same high-risk medication | Read More |
| 243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | yes | Process | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program | Read More |
| 261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | yes | Process | Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness | Read More |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | no | Process | Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated | Read More |
| 268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | no | Process | All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year | Read More |
| 275 | Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | no | Process | Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy | Read More |
| 265 | Biopsy Follow-Up | yes | Process | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient | Read More |
| 271 | Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | no | Process | Percentage of patients regardless of age with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the year prior and current year are considered adequately screened to prevent overuse of X-ray assessment | Read More |
| 320 | Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | yes | Process | Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Read More |
| 325 | Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | yes | Process | Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition | Read More |
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | no | Process | Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period | Read More |
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | yes | Process | Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms | Read More |
| 332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | yes | Process | Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis | Read More |
| 333 | Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | yes | Efficiency | Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis | Read More |
| 337 | Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier | no | Process | Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test | Read More |
| 338 | HIV Viral Load Suppression | yes | Outcome | The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year | Read More |
| 342 | Pain Brought Under Control Within 48 Hours | yes | Outcome | Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours | Read More |
| 343 | Screening Colonoscopy Adenoma Detection Rate | yes | Outcome | The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy | Read More |
| 370 | Depression Remission at Twelve Months | yes | Outcome | The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event | Read More |
| 391 | Follow-Up After Hospitalization for Mental Illness (FUH) | yes | Process | The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: • The percentage of discharges for which the patient received follow-up within 30 days of discharge. • The percentage of discharges for which the patient received follow-up within 7 days of discharge. | Read More |
| 390 | Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | yes | Process | Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment | Read More |
| 387 | Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | no | Process | Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period | Read More |
| 386 | Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | yes | Process | Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually | Read More |
| 383 | Adherence to Antipsychotic Medications For Individuals with Schizophrenia | yes | Intermediate Outcome | Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months) | Read More |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | yes | Process | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Read More |
| 371 | Depression Utilization of the PHQ-9 Tool | no | Process | The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter | Read More |
| 394 | Immunizations for Adolescents | no | Process | The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday | Read More |
| 412 | Documentation of Signed Opioid Treatment Agreement | yes | Process | All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record | Read More |
| 410 | Psoriasis: Clinical Response to Systemic Medications | yes | Outcome | Percentage of psoriasis vulgaris patients receiving systemic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment | Read More |
| 408 | Opioid Therapy Follow-up Evaluation | yes | Process | All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record | Read More |
| 401 | Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | no | Process | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission period | Read More |
| 400 | One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | no | Process | Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection | Read More |
| 398 | Optimal Asthma Control | yes | Outcome | Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation | Read More |
| 402 | Tobacco Use and Help with Quitting Among Adolescents | no | Process | The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user | Read More |
| 435 | Quality of Life Assessment For Patients With Primary Headache Disorders | yes | Patient Reported Outcome | Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved | Read More |
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | no | Process | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user | Read More |
| 419 | Overuse of Imaging for the Evaluation of Primary Headache | yes | Process | Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present | Read More |
| 418 | Osteoporosis Management in Women Who Had a Fracture | no | Process | The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture | Read More |
| 414 | Evaluation or Interview for Risk of Opioid Misuse | yes | Process | All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record | Read More |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | no | Process | Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: *Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR *Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR *Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL | Read More |
| 439 | Age Appropriate Screening Colonoscopy | yes | Efficiency | The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31 | Read More |
| 442 | Persistence of Beta-Blocker Treatment After a Heart Attack | no | Process | The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with adiagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge | Read More |
| 443 | Non-Recommended Cervical Cancer Screening in Adolescent Females | yes | Process | The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer | Read More |
| 444 | Medication Management for People with Asthma | yes | Process | The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period | Read More |
| 468 | Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | yes | Process | Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment | Read More |
| 474 | Zoster (Shingles) Vaccination | no | Process | The percentage of patients aged 50 years and older who have had a Varicella Zoster (shingles) vaccination. | Read More |
| 052 | Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | no | Process | Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator | Read More |
How to Select MIPS Improvement Activities
Step 1 : Determine how many points are needed for successful reporting.
- • 40 points: The standard number of required points and the maximum score for this Performance Category.
- • 20 points: For small or rural practices, HPSAs, or non-patient facing clinicians/groups.
- • 0 points: Certified Patient Centered Medical Homes receive full credit. A Patient Centered Medical Home must be attested to and will not automatically be classified by CMS as such.
Step 2 : Select Improvement Activities
High-weighted activities are worth 20 points, while medium-weight activities are worth 10 points. Participants can select any combination of activities to meet the requirement.
Recommended Improvement Activities
| Activity Id | Activity Name | Activity Weighting | Activity Description | Details |
|---|---|---|---|---|
| IA_EPA_3 | Collection and use of patient experience and satisfaction data on access | Medium | Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. | Read More |
| IA_CC_2 | Implementation of improvements that contribute to more timely communication of test results | Medium | Timely communication of test results defined as timely identification of abnormal test results with timely follow-up. | Read More |
| IA_CC_8 | Implementation of documentation improvements for practice/process improvements | Medium | Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure). | Read More |
| IA_BE_14 | Engage Patients and Families to Guide Improvement in the System of Care | High | Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient's status, adherence, comprehension, and indicators of clinical concern. | Read More |
| IA_PSPA_5 | Annual registration in the Prescription Drug Monitoring Program | Medium | Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months. | Read More |
| IA_AHE_1 | Engagement of New Medicaid Patients and Follow-up | High | Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity. | Read More |