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 |
|---|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 113 | Colorectal Cancer Screening | no | Process | Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 182 | Functional Outcome Assessment | yes | Process | Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies | 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 overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 405 | Appropriate Follow-up Imaging for Incidental Abdominal Lesions | yes | Process | Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow-up imaging recommended based on radiological findings. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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_AHE_6 | Provide Education Opportunities for New Clinicians | High | MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas. | Read More |
| IA_PSPA_21 | Implementation of fall screening and assessment programs | Medium | Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk). | Read More |
| IA_PSPA_22 | CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain | High | Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course "Applying CDC's Guideline for Prescribing Opioids" that reviews the 2016 "Guideline for Prescribing Opioids for Chronic Pain." Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score. | Read More |
| IA_PSPA_2 | Participation in MOC Part IV | Medium | In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV97. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program,98 National Cardiovascular Data Registry (NCDR) Clinical Quality Coach,99 Quality Practice Initiative Certification Program,100 American Board of Medical Specialties Practice Performance Improvement Module101 or American Society of Anesthesiologists (ASA) Simulation Education Network,102 for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE);103 American Psychiatric Association (APA) Performance in Practice modules.104 | Read More |
| IA_PSPA_6 | Consultation of the Prescription Drug Monitoring Program | High | Clinicians would attest to reviewing the patients' history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days. For the transition year, clinicians would attest to 60 percent review of applicable patient's history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient's history performance. | Read More |
| IA_BE_15 | Engagement of Patients, Family, and Caregivers in Developing a Plan of Care | Medium | Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology. | Read More |
| IA_CC_13 | Practice Improvements for Bilateral Exchange of Patient Information | Medium | Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following: - Participate in a Health Information Exchange if available; and/or - Use structured referral notes. | Read More |
| IA_PM_7 | Use of QCDR for feedback reports that incorporate population health | High | Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations. | Read More |