This measure set was for 2018 MIPS Quality reporting. View 2019 version ->
CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.
| Quality Id | Measure Name | High Priority | Measure Type | Measure Description | Full Specifications |
|---|---|---|---|---|---|
| 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 |
| 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 |
| 047 | 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 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 (<140/90mmHg) during the measurement period | 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 by the performing physician | 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 submitting 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 |
| 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 |
| 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 |
| 418 | Osteoporosis Management in Women Who Had a Fracture | No | Process | The percentage of women age 50-85 who suffered a fracture 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 |
| 422 | Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | Yes | Process | Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse | Read More |
| 428 | Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | No | Process | Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines | Read More |
| 429 | Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | Yes | Process | Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse | 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 |
| 432 | Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | Yes | Outcome | Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery | Read More |
| 433 | Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | Yes | Outcome | Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery | Read More |
| 434 | Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair | Yes | Outcome | Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery | Read More |
| 443 | Non-Recommended Cervical Cancer Screening in Adolescent Females | No | Process | The percentage of adolescent females 16–20 years of age screened unnecessarily for cervical cancer | Read More |
| 447 | Chlamydia Screening and Follow Up | No | Process | The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period | Read More |
| 448 | Appropriate Work Up Prior to Endometrial Ablation | Yes | Process | Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation | Read More |