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 |
|---|---|---|---|---|---|
| 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 |
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | No | Process | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer | 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 |
| 143 | Oncology: Medical and Radiation – Pain Intensity Quantified | Yes | Process | Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified | Read More |
| 144 | Oncology: Medical and Radiation – Plan of Care for Pain | Yes | Process | Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain | 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 |
| 250 | Radical Prostatectomy Pathology Reporting | No | Process | Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status | 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 |
| 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 |
| 449 | HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies | No | Process | Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies | Read More |
| 450 | Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy | No | Process | Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab | Read More |
| 451 | RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | No | Process | Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed | Read More |
| 452 | Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) 4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | No | Process | Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies | Read More |
| 453 | Proportion Receiving Chemotherapy in the Last 14 Days of Life | No | Process | Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life | Read More |
| 454 | Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life | No | Outcome | Proportion of patients who died from cancer with more than one emergency room visit in the last 30 days of life | Read More |
| 455 | Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life | No | Outcome | Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life | Read More |
| 456 | Proportion Not Admitted To Hospice | No | Process | Proportion of patients who died from cancer not admitted to hospice | Read More |
| 457 | Proportion Admitted to Hospice for less than 3 days | No | Outcome | Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there | Read More |