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 do 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 Measures
| Quality Id | Measure Name | High Priority | Measure Type | Details | Measure Description | Full Specifications |
|---|---|---|---|---|---|---|
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | Yes | Process | Details | Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Read More |
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | No | Process | Details | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis | Read More |
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | Yes | Process | Details | 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 | Details | 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 |
| 046 | Medication Reconciliation Post-Discharge | Yes | Process | Details | 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 | Details | 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 | Care Plan | Yes | Process | Details | 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 | Details | 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 | Details | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | Read More |
| 112 | Breast Cancer Screening | No | Process | Details | Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer | Read More |
| 131 | Pain Assessment and Follow-Up | Yes | Process | Details | 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 |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | No | Process | Details | 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 |
| 130 | Documentation of Current Medications in the Medical Record | Yes | Process | Details | 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 |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | No | Process | Details | 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 |
| 113 | Colorectal Cancer Screening | No | Process | Details | Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer | Read More |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Yes | Process | Details | 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 |
| 204 | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | No | Process | Details | Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period | Read More |
| 205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | No | Process | Details | 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 |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | No | Process | Details | 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 | Details | 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 |
| 268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | No | Process | Details | 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 |
| 255 | Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | No | Process | Details | Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED) | Read More |
| 254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | No | Process | Details | Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location | Read More |
| 265 | Biopsy Follow-Up | Yes | Process | Details | 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 | Details | 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 |
| 335 | Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse) | No | Outcome | Details | Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication | Read More |
| 336 | Maternity Care: Post-Partum Follow-Up and Care Coordination | Yes | Process | Details | Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning | Read More |
| 342 | Pain Brought Under Control Within 48 Hours | Yes | Outcome | Details | 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 |
| 358 | Patient-Centered Surgical Risk Assessment and Communication | Yes | Process | Details | Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon | Read More |
| 387 | Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | No | Process | Details | 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 |
| 402 | Tobacco Use and Help with Quitting Among Adolescents | No | Process | Details | 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 |
| 401 | Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | No | Process | Details | 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 reporting period | Read More |
| 400 | One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | No | Process | Details | 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 |
| 418 | Osteoporosis Management in Women Who Had a Fracture | No | Process | Details | 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 | Details | Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse | Read More |
| 429 | Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | Yes | Process | Details | 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 | Details | 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 | Details | 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 | Details | 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 | Details | 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 | Details | 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 | Details | 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 | Details | 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 |
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