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"code": "F31.4" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.5" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.60" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.61" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.62" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.63" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.64" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.70" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.71" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.72" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.73" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.74" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.75" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.76" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.77" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.78" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.4" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.5" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.A" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.40" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.41" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.42" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.8" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.21" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.23" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O90.6" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.340" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.341" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.342" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.343" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.345" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9717" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8431" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8510" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8432" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8511" } ] } ] }, { "title": "Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "176", "description": "If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "infectiousDisease", "internalMedicine", "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_176_MIPSCQM.pdf" } }, { "title": "Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2523", "measureId": "177", "description": "Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the measurement year.", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_177_MIPSCQM.pdf" } }, { "title": "Rheumatoid Arthritis (RA): Functional Status Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "178", "description": "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.", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_178_MIPSCQM.pdf" } }, { "title": "Rheumatoid Arthritis (RA): Glucocorticoid Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "180", "description": "Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_180_MIPSCQM.pdf" } }, { "measureId": "ACR12", "title": "Disease Activity Measurement for Patients with PsA", "description": "If a patient has psoriatic arthritis, then disease activity using a standardized measurement tool should be assessed at >=50% of encounters for PsA.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "firstPerformanceYear": 2020, "allowedVendors": [ "5598408", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0053" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACR14", "title": "Gout: Serum Urate Target", "description": "The percentage of patients aged 18 and older with at least one clinician encounter (including telehealth) during the measurement period and a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.0 mg/dL.", "nqfId": "2549e", "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "firstPerformanceYear": 2020, "allowedVendors": [ "5598408", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0053" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACR15", "title": "Safe Hydroxychloroquine Dosing", "description": "If a patient is using hydroxychloroquine, then the average daily dose should be less than or equal to 5 mg/kg", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "firstPerformanceYear": 2021, "allowedVendors": [ "5598408", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0053" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0058", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of certified EHR to capture patient reported outcomes", "description": "To improve patient access, perform activities beyond routine care that enable capture of patient reported outcomes (for example, related to functional status, symptoms and symptom burden, health behaviors, or patient experience) or patient activation measures (that is, measures of patient involvement in their care) through use of certified electronic health record technology, and record these outcomes data for clinician review.", "measureId": "IA_BE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "description": "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.", "measureId": "IA_BE_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002" ] }, { "category": "ia", "title": "Tobacco use", "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", "measureId": "IA_BMH_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "G0053", "G0059" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of telehealth services that expand practice access", "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", "measureId": "IA_EPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0053", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Completion of an Accredited Safety or Quality Improvement Program", "description": "Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:• The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;• The activity must have specific, measurable aim(s) for improvement;• The activity must include interventions intended to result in improvement;• The activity must include data collection and analysis of performance data to assess the impact of the interventions; and• The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).", "measureId": "IA_PSPA_28", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0053" ] } ], "costMeasures": [ { "category": "cost", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "G0056", "M0001", "M0005", "M0002" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", 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false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. 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The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group 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"measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "G0054", "clinicalTopic": "Stroke Care and Prevention", "title": "Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes", "description": "The Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP focuses on the clinical theme of providing fundamental prevention and treatment of those patients at risk for or that have had a stroke.", "specialtiesMostApplicableTo": [ "Neurology", "Neurosurgical", "Vascular Surgery" ], "clinicalTopics": "Stroke Care and Prevention", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Advance Care Plan", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureId": "047", "description": "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 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"physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" }, "eligibilityOptions": [ { "minAge": 65, "optionGroup": "00", "procedureCodes": [ { "code": "90791", "placesOfServiceExclusions": [ "23" ] }, { "code": "90832", "placesOfServiceExclusions": [ "23" ] }, { "code": "90834", "placesOfServiceExclusions": [ "23" ] }, { "code": "90837", "placesOfServiceExclusions": [ "23" ] }, { "code": "90845", "placesOfServiceExclusions": [ "23" ] }, { "code": "90846", "placesOfServiceExclusions": [ "23" ] }, { "code": "90847", "placesOfServiceExclusions": [ "23" ] }, { "code": "99202", "placesOfServiceExclusions": [ "23" ] }, { "code": "99203", "placesOfServiceExclusions": [ "23" ] }, { "code": "99204", "placesOfServiceExclusions": [ "23" ] }, { "code": "99205", "placesOfServiceExclusions": [ "23" ] }, { "code": "99212", "placesOfServiceExclusions": [ "23" ] }, { "code": "99213", "placesOfServiceExclusions": [ "23" ] }, { "code": "99214", "placesOfServiceExclusions": [ "23" ] }, { "code": "99215", "placesOfServiceExclusions": [ "23" ] }, { "code": "99221", "placesOfServiceExclusions": [ "23" ] }, { "code": "99222", "placesOfServiceExclusions": [ "23" ] }, { "code": "99223", "placesOfServiceExclusions": [ "23" ] }, { "code": "99231", "placesOfServiceExclusions": [ "23" ] }, { "code": "99232", "placesOfServiceExclusions": [ "23" ] }, { "code": "99233", "placesOfServiceExclusions": [ "23" ] }, { "code": "99234", "placesOfServiceExclusions": [ "23" ] }, { "code": "99235", "placesOfServiceExclusions": [ "23" ] }, { "code": "99236", "placesOfServiceExclusions": [ "23" ] }, { "code": "99291", "placesOfServiceExclusions": [ "23" ] }, { "code": "99304", "placesOfServiceExclusions": [ "23" ] }, { "code": "99305", "placesOfServiceExclusions": [ "23" ] }, { "code": "99306", "placesOfServiceExclusions": [ "23" ] }, { "code": "99307", "placesOfServiceExclusions": [ "23" ] }, { "code": "99308", "placesOfServiceExclusions": [ "23" ] }, { "code": "99309", "placesOfServiceExclusions": [ "23" ] }, { "code": "99310", "placesOfServiceExclusions": [ "23" ] }, { "code": "99341", "placesOfServiceExclusions": [ "23" ] }, { "code": "99342", "placesOfServiceExclusions": [ "23" ] }, { "code": "99344", "placesOfServiceExclusions": [ "23" ] }, { "code": "99345", "placesOfServiceExclusions": [ "23" ] }, { "code": "99347", "placesOfServiceExclusions": [ "23" ] }, { "code": "99348", "placesOfServiceExclusions": [ "23" ] }, { "code": "99349", "placesOfServiceExclusions": [ "23" ] }, { "code": "99350", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0402", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0438", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0439", "placesOfServiceExclusions": [ "23" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9692" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1123F" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1124F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "1123F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Stroke and Stroke Rehabilitation: Thrombolytic Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "187", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "emergencyMedicine", "neurosurgical" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_187_MIPSCQM.pdf" } }, { "title": "Controlling High Blood Pressure", "eMeasureId": "CMS165v11", "nqfEMeasureId": null, "nqfId": null, "measureId": "236", "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0056", "M0002" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" }, "eMeasureUuid": "2c928082-7a14-d92c-017a-67b6f9971ea8", "strata": [ { "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "EB3E42F6-9774-4066-8CA8-4329C95E4541", "denominatorUuid": "66167A47-3FD1-4E48-A51F-750ED6FF9147", "numeratorUuid": "FDF9F696-67F2-4AE6-953C-5DDE27BB93E7", "denominatorExclusionUuid": "CD4A4AD6-3C0B-4D7B-9751-F1A9268DF402" } } ], "eligibilityOptions": [ { "diagnosisCodes": [ "I10" ], "maxAge": 85, "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G0031" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2115" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2116" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2118" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9231" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9740" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9910" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8752" }, { "code": "G8754" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8754" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8755" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8752" }, { "code": "G8755" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8756" } ] } ] }, { "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "326", "description": "Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_326_MIPSCQM.pdf" } }, { "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "344", "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society for Vascular Surgeons", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "neurosurgical", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_344_MIPSCQM.pdf" } }, { "title": "Clinical Outcome Post Endovascular Stroke Treatment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "409", "description": "Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "neurosurgical" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_409_MIPSCQM.pdf" }, "overallAlgorithm": "split", "strata": [ { "name": "reporting", "description": "Percentage of patients with mRS score assessed at 90 days following endovascular stroke intervention" }, { "name": "performance", "description": "Percentage of patients with mRS score of 0 to 2 assessed at 90 days following endovascular stroke intervention" } ] }, { "title": "Door to Puncture Time for Endovascular Stroke Treatment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "413", "description": "Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "neurosurgical" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_413_MIPSCQM.pdf" } }, { "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "eMeasureId": "CMS347v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "438", "description": "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: \n*All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR \n*Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR \n*Patients aged 40-75 years with a diagnosis of diabetes", "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0056" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_438_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms347v6" }, "eMeasureUuid": "2c928082-7fac-c041-017f-b8180fec068b", "strata": [ { "name": "clinicalASCVD", "description": "All patients with an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) or ever had an ASCVD procedure", "eMeasureUuids": { "initialPopulationUuid": "B12E750E-E32A-4DAF-93A4-2902B9A7A006", "denominatorUuid": "D7210073-99D6-4616-8511-B15FF2C0DC36", "denominatorExclusionUuid": "5912E99B-963C-4F45-AD54-95D17670B56C", "numeratorUuid": "0DEB457A-D340-42D2-BD19-8038E502F8AA", "denominatorExceptionUuid": "2F1166B5-43F2-4E45-BC3D-2E399BBD41FF" } }, { "name": ">=20Familial", "description": "Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia", "eMeasureUuids": { "initialPopulationUuid": "0EC4214D-3153-4AAB-84E0-E9F18EB384B5", "denominatorUuid": "4138280C-EE28-4B9D-A963-B9EB69CA2C8B", "denominatorExclusionUuid": "EC8E047A-242B-4798-8A75-09BADEF9C278", "numeratorUuid": "52221AD6-F254-4BD4-9FB5-07B0D9E14F32", "denominatorExceptionUuid": "9F91E492-AEFF-45D3-8637-24DA32CC3363" } }, { "name": "between40And75", "description": "Patients aged 40-75 years with a diagnosis of diabetes", "eMeasureUuids": { "initialPopulationUuid": "B2FD2F54-F64B-446A-B8D6-69E87CF6B1DB", "denominatorUuid": "733BFDF4-72B5-4474-95CA-AD14BDD0F739", "denominatorExclusionUuid": "800774E8-D7E7-45CF-8EF6-8D6F8538F60F", "numeratorUuid": "C7164728-E597-499F-80DD-F6E42981E34F", "denominatorExceptionUuid": "64BF25A1-2691-494E-B51F-1B99F5FCE795" } } ] }, { "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "441", "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND Most recent tobacco status is Tobacco Free -- AND Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND Statin Use Unless Contraindicated", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_441_MIPSCQM.pdf" } } ], "iaMeasures": [ { "category": "ia", "title": "Use of certified EHR to capture patient reported outcomes", "description": "To improve patient access, perform activities beyond routine care that enable capture of patient reported outcomes (for example, related to functional status, symptoms and symptom burden, health behaviors, or patient experience) or patient activation measures (that is, measures of patient involvement in their care) through use of certified electronic health record technology, and record these outcomes data for clinician review.", "measureId": "IA_BE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "measureId": "IA_BE_24", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0057", "G0059", "M0005", "M0002" ] }, { "category": "ia", "title": "Practice Improvements to Align with OpenNotes Principles", "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", "measureId": "IA_CC_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0058", "M0005", "M0002" ] }, { "category": "ia", "title": "Patient Navigator Program", "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", "measureId": "IA_CC_17", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "M0001" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "G0056", "M0005" ] }, { "category": "ia", "title": "Implementation of episodic care management practice improvements", "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or• Managing care intensively through new diagnoses, injuries and exacerbations of illness.", "measureId": "IA_PM_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0054", "M0001" ] } ], "costMeasures": [ { "category": "cost", "title": "Intracranial Hemorrhage or Cerebral Infarction", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Intracranial Hemorrhage or Cerebral Infarction episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive inpatient treatment for cerebral infarction or intracranial hemorrhage during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "measureId": "COST_IHCI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-ich-cva.pdf" }, "allowedPrograms": [ "mips", "app1", "G0054" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "G0055", "clinicalTopic": "Heart Disease", "title": "Advancing Care for Heart Disease", "description": "The Advancing Care for Heart Disease MVP focuses on the clinical theme of providing fundamental treatment and management of costly clinical conditions that contribute to, or may result from, heart disease.", "specialtiesMostApplicableTo": [ "Cardiology", "Internal Medicine", "Family Medicine" ], "clinicalTopics": "Heart Disease", "hasCahps": false, "hasOutcomeAdminClaims": true, "qualityMeasures": [ { "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS135v11", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureId": "005", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart 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"2c928083-7f47-c81f-017f-8e1c03421dc7", "strata": [ { "name": "LVSD", "description": "Patients with left ventricular systolic dysfunction (LVEF <40%)", "eMeasureUuids": { "initialPopulationUuid": "4E0D3490-1061-4C2C-B49D-4A31B2DBC197", "denominatorUuid": "854ADFB2-FAFB-4632-9D74-19DB7EA25034", "numeratorUuid": "45097018-5150-485C-8D87-61BB9BB0943B", "denominatorExceptionUuid": "90C84B31-6F60-41C8-A576-37589C8EEBF5" } }, { "name": "priorMI", "description": "Patients with a prior (within the past 3 years) myocardial infarction", "eMeasureUuids": { "initialPopulationUuid": "073B2941-D099-4142-97C0-E907CD7215D8", "denominatorUuid": "00007C18-CC58-4BDB-9759-C08B59B809B1", "numeratorUuid": "82ADC103-BB4D-4436-A0DF-11D8E5907473", "denominatorExceptionUuid": "04EED69A-0FFD-4EF9-80BD-2A0D3C88BBE4" } } ] }, { "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS144v11", "nqfEMeasureId": "0083e", "nqfId": "0083", "measureId": 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{ "code": "99291", "placesOfServiceExclusions": [ "23" ] }, { "code": "99304", "placesOfServiceExclusions": [ "23" ] }, { "code": "99305", "placesOfServiceExclusions": [ "23" ] }, { "code": "99306", "placesOfServiceExclusions": [ "23" ] }, { "code": "99307", "placesOfServiceExclusions": [ "23" ] }, { "code": "99308", "placesOfServiceExclusions": [ "23" ] }, { "code": "99309", "placesOfServiceExclusions": [ "23" ] }, { "code": "99310", "placesOfServiceExclusions": [ "23" ] }, { "code": "99341", "placesOfServiceExclusions": [ "23" ] }, { "code": "99342", "placesOfServiceExclusions": [ "23" ] }, { "code": "99344", "placesOfServiceExclusions": [ "23" ] }, { "code": "99345", "placesOfServiceExclusions": [ "23" ] }, { "code": "99347", "placesOfServiceExclusions": [ "23" ] }, { "code": "99348", "placesOfServiceExclusions": [ "23" ] }, { "code": "99349", "placesOfServiceExclusions": [ "23" ] }, { "code": "99350", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0402", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0438", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0439", "placesOfServiceExclusions": [ "23" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9692" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1123F" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1124F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "1123F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "eMeasureId": "CMS69v11", "nqfEMeasureId": null, "nqfId": null, "measureId": "128", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if 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] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.A" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.40" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.41" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.42" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.8" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.21" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.23" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O90.6" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.340" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.341" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.342" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.343" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.345" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9717" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8431" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8510" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8432" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8511" } ] } ] }, { "title": "Use of High-Risk Medications in Older Adults", "eMeasureId": "CMS156v11", "nqfEMeasureId": null, "nqfId": "0022", "measureId": "238", "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0055", "M0004" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "geriatrics", "internalMedicine", "oncology", "ophthalmology", "otolaryngology", "pulmonology", "rheumatology", "skilledNursingFacility", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_238_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms156v11" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "eMeasureUuids": { "initialPopulationUuid": "064940DC-3F04-4B31-88CA-367BE20AC510", "denominatorUuid": "CD3CCAD3-3E90-4094-9987-9A9D2A5D574D", "numeratorUuid": "E384D9B0-6AD6-45BC-B562-A57E46FC1E90", "denominatorExclusionUuid": "CEC58D2D-4525-45B8-B320-FFB35B654DA8" }, "name": "overall" }, { "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.", "eMeasureUuids": { "initialPopulationUuid": "5E28FE53-02D9-4A14-9721-74729FBF2F73", "denominatorUuid": "5BE6C6E2-64FA-49D5-8D2E-B977E2AB62A7", "numeratorUuid": "5577FDAE-5153-4B75-9B85-59CEF09CFC82", "numeratorExclusionUuid": "C813AAC7-6D05-45D0-838D-467A837ECEC0", "denominatorExclusionUuid": "82D62AA5-015B-4256-AF2B-C43D52622EFB" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "2B4CFB1B-43D2-4ABA-AE55-CCF174208A3B", "denominatorUuid": "725E725B-DF32-429A-BAEE-444AD4CE5FC7", "numeratorUuid": "35C1118F-EBF8-470F-8B70-150CB04435AA", "denominatorExclusionUuid": "AEA06864-DA4F-4ECD-93EC-BA6B94930337" }, "name": "totalRate" } ], "eMeasureUuid": "2c928084-808a-9589-0180-d74bf7b7164d" }, { "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0643", "measureId": "243", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [ "registry" ], "isClinicalGuidelineChanged": false, "isIcdImpacted": true, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_243_MIPSCQM.pdf" } }, { "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "326", "description": "Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_326_MIPSCQM.pdf" } }, { "title": "Functional Status Assessments for Heart Failure", "eMeasureId": "CMS90v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "377", "description": "Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms090v12" }, "eMeasureUuid": "2c928082-7fac-c041-017f-e1110496119a", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, PROMIS-29) present in the EHR within two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial FSA", "eMeasureUuids": { "initialPopulationUuid": "2FD2D5BD-5766-427F-9DE7-F0C4FD319A86", "denominatorUuid": "DD21E3D1-8F5B-41EE-878A-4F4E77AE684A", "numeratorUuid": "A01BF233-7E85-4D00-9866-FD2C245F2A3F", "denominatorExclusionUuid": "693817B3-25B9-4990-9526-C4B559E7EDDF" } } ] }, { "title": "Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "measureId": "392", "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender: Submission Age Criteria 1: Females 18-64 years of age Submission Age Criteria 2: Males 18-64 years of age Submission Age Criteria 3: Females 65 years of age and older Submission Age Criteria 4: Males 65 years of age and older", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_392_MIPSCQM.pdf" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "female18-64", "description": "Females 18-64 years of age" }, { "name": "male18-64", "description": "Males 18-64 years of age" }, { "name": "female65+", "description": "Females 65 years of age and older" }, { "name": "male65+", "description": "Males 65 years of age and older" }, { "name": "overall", "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days" } ] }, { "title": "Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "393", "description": "Infection rate following CIED device implantation, replacement, or revision.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_393_MIPSCQM.pdf" } }, { "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "441", "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND Most recent tobacco status is Tobacco Free -- AND Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND Statin Use Unless Contraindicated", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_441_MIPSCQM.pdf" } } ], "iaMeasures": [ { "category": "ia", "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health", "description": "Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:\r\n• Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or \r\n• Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or\r\n• Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. \r\n\r\nDrivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.", "measureId": "IA_AHE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "M0005" ] }, { "category": "ia", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "measureId": "IA_BE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0055", "G0058", "M0005" ] }, { "category": "ia", "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "description": "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.", "measureId": "IA_BE_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002" ] }, { "category": "ia", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "measureId": "IA_BE_24", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Drug Cost Transparency", "description": "Provide counseling to patients and/or their caregivers regarding: costs of medications using a real time benefit tool (RTBT) which provides to the prescriber real-time patient-specific formulary and benefit information for drugs, including cost-sharing for a beneficiary.", "measureId": "IA_BE_25", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0055" ] }, { "category": "ia", "title": "Implementation of practices/processes for developing regular individual care plans", "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.", "measureId": "IA_CC_9", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0055", "G0058" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "G0056", "M0005" ] }, { "category": "ia", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "measureId": "IA_PM_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "M0001", "M0002" ] }, { "category": "ia", "title": "Administration of the AHRQ Survey of Patient Safety Culture", "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html). 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.", "measureId": "IA_PSPA_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056" ] }, { "category": "ia", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "G0058", "G0059" ] } ], "costMeasures": [ { "category": "cost", "title": "Elective Outpatient Percutaneous Coronary Intervention (PCI)", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Outpatient PCI episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "measureId": "COST_EOPCI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-op-pci.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055" ] }, { "category": "cost", "title": "ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The STEMI with PCI episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who present with STEMI indicating complete blockage of a coronary artery who emergently receive PCI as treatment during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "measureId": "COST_STEMI_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-stemi-pci-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055" ] }, { "category": "cost", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "G0056", "M0001", "M0005", "M0002" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [ { "title": "Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3612", "measureId": "492", "description": "Annual risk-standardized rate of acute, unplanned cardiovascular-related admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with heart failure (HF) or cardiomyopathy.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": null } ] }, { "mvpId": "G0056", "clinicalTopic": "Chronic Disease Management", "title": "Optimizing Chronic Disease Management", "description": "The Optimizing Chronic Disease Management MVP focuses on the clinical theme of providing fundamental treatment and management of chronic disease such as diabetes, coronary artery disease, chronic obstructive disease, and major adult depression.", "specialtiesMostApplicableTo": [ "Cardiology", "Internal Medicine", "Family Medicine" ], "clinicalTopics": "Chronic Disease Management", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0067", "measureId": "006", "description": "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.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [ "registry" ], "isClinicalGuidelineChanged": false, "isIcdImpacted": true, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0056" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_006_MIPSCQM.pdf" } }, { "title": "Advance Care Plan", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureId": "047", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "G0056", "M0001", "M0002", "M0003", "M0004" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" }, "eligibilityOptions": [ { "minAge": 65, "optionGroup": "00", "procedureCodes": [ { "code": "90791", "placesOfServiceExclusions": [ "23" ] }, { "code": "90832", "placesOfServiceExclusions": [ "23" ] }, { "code": "90834", "placesOfServiceExclusions": [ "23" ] }, { "code": "90837", "placesOfServiceExclusions": [ "23" ] }, { "code": "90845", "placesOfServiceExclusions": [ "23" ] }, { "code": "90846", "placesOfServiceExclusions": [ "23" ] }, { "code": "90847", "placesOfServiceExclusions": [ "23" ] }, { "code": "99202", "placesOfServiceExclusions": [ "23" ] }, { "code": "99203", "placesOfServiceExclusions": [ "23" ] }, { "code": "99204", "placesOfServiceExclusions": [ "23" ] }, { "code": "99205", "placesOfServiceExclusions": [ "23" ] }, { "code": "99212", "placesOfServiceExclusions": [ "23" ] }, { "code": "99213", "placesOfServiceExclusions": [ "23" ] }, { "code": "99214", "placesOfServiceExclusions": [ "23" ] }, { "code": "99215", "placesOfServiceExclusions": [ "23" ] }, { "code": "99221", "placesOfServiceExclusions": [ "23" ] }, { "code": "99222", "placesOfServiceExclusions": [ "23" ] }, { "code": "99223", "placesOfServiceExclusions": [ "23" ] }, { "code": "99231", "placesOfServiceExclusions": [ "23" ] }, { "code": "99232", "placesOfServiceExclusions": [ "23" ] }, { "code": "99233", "placesOfServiceExclusions": [ "23" ] }, { "code": "99234", "placesOfServiceExclusions": [ "23" ] }, { "code": "99235", "placesOfServiceExclusions": [ "23" ] }, { "code": "99236", "placesOfServiceExclusions": [ "23" ] }, { "code": "99291", "placesOfServiceExclusions": [ "23" ] }, { "code": "99304", "placesOfServiceExclusions": [ "23" ] }, { "code": "99305", "placesOfServiceExclusions": [ "23" ] }, { "code": "99306", "placesOfServiceExclusions": [ "23" ] }, { "code": "99307", "placesOfServiceExclusions": [ "23" ] }, { "code": "99308", "placesOfServiceExclusions": [ "23" ] }, { "code": "99309", "placesOfServiceExclusions": [ "23" ] }, { "code": "99310", "placesOfServiceExclusions": [ "23" ] }, { "code": "99341", "placesOfServiceExclusions": [ "23" ] }, { "code": "99342", "placesOfServiceExclusions": [ "23" ] }, { "code": "99344", "placesOfServiceExclusions": [ "23" ] }, { "code": "99345", "placesOfServiceExclusions": [ "23" ] }, { "code": "99347", "placesOfServiceExclusions": [ "23" ] }, { "code": "99348", "placesOfServiceExclusions": [ "23" ] }, { "code": "99349", "placesOfServiceExclusions": [ "23" ] }, { "code": "99350", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0402", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0438", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0439", "placesOfServiceExclusions": [ "23" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9692" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1123F" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1124F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "1123F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment", "eMeasureId": "CMS161v11", "nqfEMeasureId": "0104e", "nqfId": null, "measureId": "107", "description": "Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit", "measureType": "process", "isHighPriority": false, "primarySteward": "Mathematica", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0056" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms161v11" }, "eMeasureUuid": "2c928082-7a14-d92c-017a-5d428e9516ff", "strata": [ { "description": "Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit", "eMeasureUuids": { "initialPopulationUuid": "DC8E1A1C-BD9E-4F8E-8584-388BECBEF0E8", "denominatorUuid": "2B4E018E-7F6A-4C15-AD7B-AECABB45D4A7", "numeratorUuid": "D732F43D-14F0-44C4-B59E-EB48BA469080" } } ] }, { "title": "Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0066", "measureId": "118", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB therapy.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0056" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "endocrinology", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_118_MIPSCQM.pdf" } }, { "title": "Controlling High Blood Pressure", "eMeasureId": "CMS165v11", "nqfEMeasureId": null, "nqfId": null, "measureId": "236", "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0056", "M0002" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" }, "eMeasureUuid": "2c928082-7a14-d92c-017a-67b6f9971ea8", "strata": [ { "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "EB3E42F6-9774-4066-8CA8-4329C95E4541", "denominatorUuid": "66167A47-3FD1-4E48-A51F-750ED6FF9147", "numeratorUuid": "FDF9F696-67F2-4AE6-953C-5DDE27BB93E7", "denominatorExclusionUuid": "CD4A4AD6-3C0B-4D7B-9751-F1A9268DF402" } } ], "eligibilityOptions": [ { "diagnosisCodes": [ "I10" ], "maxAge": 85, "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G0031" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2115" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2116" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2118" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9231" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9740" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9910" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8752" }, { "code": "G8754" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8754" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8755" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8752" }, { "code": "G8755" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8756" } ] } ] }, { "title": "CAHPS for MIPS Clinician/Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureId": "321", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "cahps", "allowedPrograms": [ "mips", "pcf", "app1", "G0056", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": { "default": "https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2496/CAHPS%20for%20MIPS%20Survey%20QAG%20V2023.pdf" } }, { "title": "Optimal Asthma Control", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "398", "description": "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.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0056" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "otolaryngology", "pediatrics", "pulmonology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_398_MIPSCQM.pdf" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "pedCtrlNoExacRisk", "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "adultCtrlNoExacRisk", "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "pedsWellCtrl", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma" }, { "name": "adultsWellCtrl", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma" }, { "name": "pedsNoRiskExac", "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma" }, { "name": "adultsNoRiskExac", "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma" } ] }, { "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "eMeasureId": "CMS347v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "438", "description": "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: \n*All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR \n*Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR \n*Patients aged 40-75 years with a diagnosis of diabetes", "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0056" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_438_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms347v6" }, "eMeasureUuid": "2c928082-7fac-c041-017f-b8180fec068b", "strata": [ { "name": "clinicalASCVD", "description": "All patients with an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) or ever had an ASCVD procedure", "eMeasureUuids": { "initialPopulationUuid": "B12E750E-E32A-4DAF-93A4-2902B9A7A006", "denominatorUuid": "D7210073-99D6-4616-8511-B15FF2C0DC36", "denominatorExclusionUuid": "5912E99B-963C-4F45-AD54-95D17670B56C", "numeratorUuid": "0DEB457A-D340-42D2-BD19-8038E502F8AA", "denominatorExceptionUuid": "2F1166B5-43F2-4E45-BC3D-2E399BBD41FF" } }, { "name": ">=20Familial", "description": "Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia", "eMeasureUuids": { "initialPopulationUuid": "0EC4214D-3153-4AAB-84E0-E9F18EB384B5", "denominatorUuid": "4138280C-EE28-4B9D-A963-B9EB69CA2C8B", "denominatorExclusionUuid": "EC8E047A-242B-4798-8A75-09BADEF9C278", "numeratorUuid": "52221AD6-F254-4BD4-9FB5-07B0D9E14F32", "denominatorExceptionUuid": "9F91E492-AEFF-45D3-8637-24DA32CC3363" } }, { "name": "between40And75", "description": "Patients aged 40-75 years with a diagnosis of diabetes", "eMeasureUuids": { "initialPopulationUuid": "B2FD2F54-F64B-446A-B8D6-69E87CF6B1DB", "denominatorUuid": "733BFDF4-72B5-4474-95CA-AD14BDD0F739", "denominatorExclusionUuid": "800774E8-D7E7-45CF-8EF6-8D6F8538F60F", "numeratorUuid": "C7164728-E597-499F-80DD-F6E42981E34F", "denominatorExceptionUuid": "64BF25A1-2691-494E-B51F-1B99F5FCE795" } } ] }, { "title": "Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3568", "measureId": "483", "description": "The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "The American Board of Family Medicine", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "nonProportion", "allowedPrograms": [ "mips", "pcf", "G0056", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_483_MIPSCQM.pdf" } } ], "iaMeasures": [ { "category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0058", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health", "description": "Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:\r\n• Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or \r\n• Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or\r\n• Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. \r\n\r\nDrivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.", "measureId": "IA_AHE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "M0005" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Promote Self-management in Usual Care", "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", "measureId": "IA_BE_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0056", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Improved Practices that Engage Patients Pre-Visit", "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.", "measureId": "IA_BE_22", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0056", "G0059" ] }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0057", "G0059", "M0005", "M0002" ] }, { "category": "ia", "title": "Care coordination agreements that promote improvements in patient tracking across settings", "description": "Establish effective care coordination and active referral management that could include one or more of the following:• Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; • Track patients referred to specialist through the entire process; and/or• Systematically integrate information from referrals into the plan of care.", "measureId": "IA_CC_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0056" ] }, { "category": "ia", "title": "Practice Improvements to Align with OpenNotes Principles", "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", "measureId": "IA_CC_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0058", "M0005", "M0002" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "G0056", "M0005" ] }, { "category": "ia", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "measureId": "IA_PM_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "M0001", "M0002" ] }, { "category": "ia", "title": "Administration of the AHRQ Survey of Patient Safety Culture", "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html). 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.", "measureId": "IA_PSPA_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056" ] }, { "category": "ia", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "G0058", "G0059" ] }, { "category": "ia", "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", "description": "Adopt a formal model for quality improvement and create a culture in which all staff, including leadership, actively participates in improvement activities that could include one or more of the following, such as:\n• Participation in multisource feedback; \n• Train all staff in quality improvement methods;\n• Integrate practice change/quality improvement into staff duties;\n• Engage all staff in identifying and testing practices changes;\n• Designate regular team meetings to review data and plan improvement cycles;\n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;\n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;\n• Participation in Bridges to Excellence;\n• Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_PSPA_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0056", "G0057", "M0005" ] } ], "costMeasures": [ { "category": "cost", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "G0056", "M0001", "M0005", "M0002" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "G0057", "clinicalTopic": "Emergency Medicine", "title": "Adopting Best Practices and Promoting Patient Safety within Emergency Medicine", "description": "The Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP focuses on important assessors of the care emergency clinicians provide to patients with undifferentiated high-risk conditions. By focusing on these specific measures and activities, emergency clinicians can reduce clinical variability, improve the quality of emergency care and potentially lower costs.", "specialtiesMostApplicableTo": [ "Emergency Medicine" ], "clinicalTopics": "Emergency Medicine", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0058", "measureId": "116", "description": "The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "pediatrics", "preventiveMedicine", "urgentCare" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_116_MIPSCQM.pdf" } }, { "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "254", "description": "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.", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Emergency Physicians", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_254_MIPSCQM.pdf" } }, { "title": "CAHPS for MIPS Clinician/Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureId": "321", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "cahps", "allowedPrograms": [ "mips", "pcf", "app1", "G0056", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": { "default": "https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2496/CAHPS%20for%20MIPS%20Survey%20QAG%20V2023.pdf" } }, { "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "331", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_331_MIPSCQM.pdf" } }, { "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "415", "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.", "measureType": "efficiency", "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_415_MIPSCQM.pdf" } }, { "measureId": "ACEP21", "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2016, "allowedVendors": [ "5133825", "1725296", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0057" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP50", "title": "ED Median Time from ED arrival to ED departure for all Adult Patients", "description": "Time (in minutes) from ED arrival to ED departure for all Adult Patients", "nqfId": null, "measureType": "outcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2020, "allowedVendors": [ "5133825", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0057" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] }, { "measureId": "ACEP52", "title": "Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain", "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT or MRI of the Lumbar Spine ordered by an emergency care provider, regardless of discharge disposition, presenting with acute, non-complex low back pain.", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "firstPerformanceYear": 2020, "allowedVendors": [ "5133825", "1725296", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0057" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "ECPR46", "title": "Avoidance of Opiates for Low Back Pain or Migraines", "description": "Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "firstPerformanceYear": 2018, "allowedVendors": [ "1718371", "5133825", "4757099", "1725296", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0057" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health", "description": "Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:\r\n• Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or \r\n• Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or\r\n• Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. \r\n\r\nDrivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.", "measureId": "IA_AHE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "M0005" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002" ] }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0057", "G0059", "M0005", "M0002" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "measureId": "IA_PSPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0057", "G0059" ] }, { "category": "ia", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "G0058", "G0059" ] }, { "category": "ia", "title": "Implementation of an ASP", "description": "Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: • Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.• Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). • Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.• Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. • Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.• Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.• Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. • Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions. • Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.• Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance.", "measureId": "IA_PSPA_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0057" ] }, { "category": "ia", "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", "description": "Adopt a formal model for quality improvement and create a culture in which all staff, including leadership, actively participates in improvement activities that could include one or more of the following, such as:\n• Participation in multisource feedback; \n• Train all staff in quality improvement methods;\n• Integrate practice change/quality improvement into staff duties;\n• Engage all staff in identifying and testing practices changes;\n• Designate regular team meetings to review data and plan improvement cycles;\n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;\n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;\n• Participation in Bridges to Excellence;\n• Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_PSPA_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0056", "G0057", "M0005" ] } ], "costMeasures": [ { "category": "cost", "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "MSPB_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0057", "G0059", "M0003", "M0004" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "G0058", "clinicalTopic": "Lower Extremity Joint Repair", "title": "Improving Care for Lower Extremity Joint Repair", "description": "The Improving Care for Lower Extremity Joint Repair MVP focuses on the clinical theme of providing fundamental treatment and management of patients with osteoarthritis and lower extremity surgical repair, such as fracture and total joint replacement, to ensure appropriate care and reduce costs.", "specialtiesMostApplicableTo": [ "Orthopedic Surgery" ], "clinicalTopics": "Lower Extremity Joint Repair", "hasCahps": false, "hasOutcomeAdminClaims": true, "qualityMeasures": [ { "title": "Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "024", "description": "Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0058" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "orthopedicSurgery", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_024_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_024_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "M48.40XA", "M48.41XA", "M48.42XA", "M48.43XA", "M48.44XA", "M48.45XA", "M48.46XA", "M48.47XA", "M48.48XA", "M84.311A", "M84.312A", "M84.319A", "M84.321A", "M84.322A", "M84.329A", "M84.331A", "M84.332A", "M84.333A", "M84.334A", "M84.339A", "M84.341A", "M84.342A", "M84.343A", "M84.350A", "M84.351A", "M84.352A", "M84.353A", "M84.359A", "M84.361A", "M84.362A", "M84.363A", "M84.364A", "M84.369A", "M84.371A", "M84.372A", "M84.373A", "M84.374A", "M84.375A", "M84.376A", "M84.38XA", "M84.750A", "M84.751A", "M84.752A", "M84.753A", "M84.754A", "M84.755A", "M84.756A", "M84.757A", "M84.759A", "S12.000A", "S12.000B", "S12.001A", "S12.001B", "S12.01XA", "S12.01XB", "S12.02XA", "S12.02XB", "S12.030A", "S12.030B", "S12.031A", "S12.031B", "S12.040A", "S12.040B", "S12.041A", "S12.041B", "S12.090A", "S12.090B", "S12.091A", "S12.091B", "S12.100A", "S12.100B", "S12.101A", "S12.101B", "S12.110A", "S12.110B", "S12.111A", "S12.111B", "S12.112A", "S12.112B", "S12.120A", "S12.120B", "S12.121A", "S12.121B", "S12.130A", "S12.130B", "S12.131A", "S12.131B", "S12.14XA", "S12.14XB", "S12.150A", "S12.150B", "S12.151A", "S12.151B", "S12.190A", "S12.190B", "S12.191A", "S12.191B", "S12.200A", "S12.200B", "S12.201A", "S12.201B", "S12.230A", "S12.230B", "S12.231A", "S12.231B", "S12.24XA", "S12.24XB", "S12.250A", "S12.250B", "S12.251A", "S12.251B", "S12.290A", "S12.290B", "S12.291A", "S12.291B", "S12.300A", "S12.300B", "S12.301A", "S12.301B", "S12.330A", "S12.330B", "S12.331A", "S12.331B", "S12.34XA", "S12.34XB", "S12.350A", "S12.350B", "S12.351A", "S12.351B", "S12.390A", "S12.390B", "S12.391A", "S12.391B", "S12.400A", "S12.400B", "S12.401A", "S12.401B", "S12.430A", "S12.430B", "S12.431A", "S12.431B", "S12.44XA", "S12.44XB", "S12.450A", "S12.450B", "S12.451A", "S12.451B", "S12.490A", "S12.490B", "S12.491A", "S12.491B", "S12.500A", "S12.500B", "S12.501A", "S12.501B", "S12.530A", "S12.530B", "S12.531A", "S12.531B", "S12.54XA", "S12.54XB", "S12.550A", "S12.550B", "S12.551A", "S12.551B", "S12.590A", "S12.590B", "S12.591A", "S12.591B", "S12.600A", "S12.600B", "S12.601A", "S12.601B", "S12.630A", "S12.630B", "S12.631A", "S12.631B", "S12.64XA", "S12.64XB", "S12.650A", "S12.650B", "S12.651A", "S12.651B", "S12.690A", "S12.690B", "S12.691A", "S12.691B", "S12.8XXA", "S12.9XXA", "S22.000A", "S22.000B", "S22.001A", "S22.001B", "S22.002A", "S22.002B", "S22.008A", "S22.008B", "S22.009A", "S22.009B", "S22.010A", "S22.010B", "S22.011A", "S22.011B", "S22.012A", "S22.012B", "S22.018A", "S22.018B", "S22.019A", "S22.019B", "S22.020A", "S22.020B", "S22.021A", "S22.021B", "S22.022A", "S22.022B", "S22.028A", "S22.028B", "S22.029A", "S22.029B", "S22.030A", "S22.030B", "S22.031A", "S22.031B", "S22.032A", "S22.032B", "S22.038A", "S22.038B", "S22.039A", "S22.039B", "S22.040A", "S22.040B", "S22.041A", "S22.041B", "S22.042A", "S22.042B", "S22.048A", "S22.048B", "S22.049A", "S22.049B", "S22.050A", "S22.050B", "S22.051A", "S22.051B", "S22.052A", "S22.052B", "S22.058A", "S22.058B", "S22.059A", "S22.059B", "S22.060A", "S22.060B", "S22.061A", "S22.061B", "S22.062A", "S22.062B", "S22.068A", "S22.068B", "S22.069A", "S22.069B", "S22.070A", "S22.070B", "S22.071A", "S22.071B", "S22.072A", "S22.072B", "S22.078A", "S22.078B", "S22.079A", "S22.079B", "S22.080A", "S22.080B", "S22.081A", "S22.081B", "S22.082A", "S22.082B", "S22.088A", "S22.088B", "S22.089A", "S22.089B", "S22.20XA", "S22.20XB", "S22.21XA", "S22.21XB", "S22.22XA", "S22.22XB", "S22.23XA", "S22.23XB", "S22.24XA", "S22.24XB", "S22.31XA", "S22.31XB", "S22.32XA", "S22.32XB", "S22.39XA", "S22.39XB", "S22.41XA", "S22.41XB", "S22.42XA", "S22.42XB", "S22.43XA", "S22.43XB", "S22.49XA", "S22.49XB", "S22.5XXA", "S22.5XXB", "S22.9XXA", "S22.9XXB", "S32.000A", "S32.000B", "S32.001A", "S32.001B", "S32.002A", "S32.002B", "S32.008A", "S32.008B", "S32.009A", "S32.009B", "S32.010A", "S32.010B", "S32.011A", "S32.011B", "S32.012A", "S32.012B", "S32.018A", "S32.018B", "S32.019A", "S32.019B", "S32.020A", "S32.020B", "S32.021A", "S32.021B", "S32.022A", "S32.022B", "S32.028A", "S32.028B", "S32.029A", "S32.029B", "S32.030A", "S32.030B", "S32.031A", "S32.031B", "S32.032A", "S32.032B", "S32.038A", "S32.038B", "S32.039A", "S32.039B", "S32.040A", "S32.040B", "S32.041A", "S32.041B", "S32.042A", "S32.042B", "S32.048A", "S32.048B", "S32.049A", "S32.049B", "S32.050A", "S32.050B", "S32.051A", "S32.051B", "S32.052A", "S32.052B", "S32.058A", "S32.058B", "S32.059A", "S32.059B", "S32.10XA", "S32.10XB", "S32.110A", "S32.110B", "S32.111A", "S32.111B", "S32.112A", "S32.112B", "S32.119A", "S32.119B", "S32.120A", "S32.120B", "S32.121A", "S32.121B", "S32.122A", "S32.122B", "S32.129A", "S32.129B", "S32.130A", "S32.130B", "S32.131A", "S32.131B", "S32.132A", "S32.132B", "S32.139A", "S32.139B", "S32.14XA", "S32.14XB", "S32.15XA", "S32.15XB", "S32.16XA", "S32.16XB", "S32.17XA", "S32.17XB", "S32.19XA", 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The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", "measureId": "IA_CC_15", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0058", "G0059" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "G0058", "G0059" ] }, { "category": "ia", "title": "Measurement and improvement at the practice and panel level", "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards that could include one or more of the following:•\tRegularly review measures of quality, utilization, patient satisfaction and other measures; and/or•\tUse relevant data sources to create benchmarks and goals for performance at the practice or panel levels.MIPS eligible clinicians can apply the measurement and quality improvement to address inequities in quality and outcomes for underserved populations, including racial, ethnic, and/or gender minorities.", "measureId": "IA_PSPA_18", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0058" ] }, { "category": "ia", "title": "Invasive Procedure or Surgery Anticoagulation Medication Management", "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.", "measureId": "IA_PSPA_27", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0058" ] } ], "costMeasures": [ { "category": "cost", "title": "Knee Arthroplasty", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Knee Arthroplasty episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive an elective knee arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "measureId": "COST_KA_1", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-knee-arthro.pdf" }, "allowedPrograms": [ "mips", "app1", "G0058" ] }, { "category": "cost", "title": "Elective Primary Hip Arthroplasty", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who receive an elective primary hip arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "measureId": "COST_PHA_1", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-el-ha.pdf" }, "allowedPrograms": [ "mips", "app1", "G0058" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [ { "title": "Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3493", "measureId": "480", "description": "This measure is a re-specified version of the measure, \"Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)\" (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (\"provider\") and assesses each provider's complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "G0058" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": {} } ] }, { "mvpId": "G0059", "clinicalTopic": "Anesthesia", "title": "Patient Safety and Support of Positive Experiences with Anesthesia", "description": "The Patient Safety and Support of Positive Experiences with Anesthesia MVP focuses on increasing quality of anesthesia care, improving postoperative outcomes, promoting patient safety, and enhancing satisfaction for patients receiving anesthesia. The measures are used for a variety of surgical procedures that anesthesiologists deliver care for, and are broadly applicable to anesthesiologists practicing within ambulatory, outpatient, and inpatient hospital settings.", "specialtiesMostApplicableTo": [ "Anesthesiology" ], "clinicalTopics": "Anesthesia", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Anesthesiology Smoking Abstinence", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "404", "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_404_MIPSCQM.pdf" } }, { "title": "Perioperative Temperature Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "424", "description": "Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_424_MIPSCQM.pdf" } }, { "title": "Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "430", "description": "Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_430_MIPSCQM.pdf" } }, { "title": "Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "463", "description": "Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_463_MIPSCQM.pdf" } }, { "title": "Multimodal Pain Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "477", "description": "Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_477_MIPSCQM.pdf" } }, { "measureId": "AQI48", "title": "Patient-Reported Experience with Anesthesia", "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. \n\nThis measure will consist of two performance rates:\n\nAQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care \n\nAQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care\n\nNOTE: The measure requires that a valid survey, as defined in the numerator of AQI48a, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI48b, a minimum number of 20 surveys with the mandatory question completed must be reported. ** In order to be scored on this measure, clinicians must report BOTH AQI48a AND AQI48b.", "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2017, "allowedVendors": [ "5551268", "6775913", "7746687", "6169123", "6704504", "4757099", "9181695", "7418330", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0059" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registryMultiPerformanceRate", "submissionMethods": [ "registry" ], "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "surveyed", "description": "The first performance rate, AQI48a, describes the percentage of surgical patients who receive a survey of their experience with anesthesia care." }, { "name": "overall", "description": "The second performance rate, AQI48b, describes the percentage of surgical patients who report a positive experience with anesthesia care." } ] }, { "measureId": "AQI69", "title": "Intraoperative Antibiotic Redosing", "description": "Percentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision (if fluoroquinolone or vancomycin, two hours) and undergo a procedure greater than two hours duration who received intraoperative antibiotic redosing at a maximum interval of two half-lives of the selected prophylactic antibiotic.", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", "firstPerformanceYear": 2021, "allowedVendors": [ "5551268", "6775913", "4757099", "7746687", "6169123", "6704504", "9181695", "7418330", "3471690" ], "allowedPrograms": [ "mips", "pcf", "G0059" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002" ] }, { "category": "ia", "title": "Improved Practices that Engage Patients Pre-Visit", "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.", "measureId": "IA_BE_22", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0056", "G0059" ] }, { "category": "ia", "title": "Tobacco use", "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", "measureId": "IA_BMH_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "G0053", "G0059" ] }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0057", "G0059", "M0005", "M0002" ] }, { "category": "ia", "title": "PSH Care Coordination", "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", "measureId": "IA_CC_15", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0058", "G0059" ] }, { "category": "ia", "title": "Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.", "description": "To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period. Reporting the PRC modifiers enables the identification of a clinician’s relationship with, and responsibility for, a patient at the time of furnishing an item or service. See the CY 2018 PFS final rule (82 FR 53232 through 53234) for more details on these codes.", "measureId": "IA_CC_19", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0059" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "measureId": "IA_PSPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0057", "G0059" ] }, { "category": "ia", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "G0058", "G0059" ] }, { "category": "ia", "title": "Use of decision support and standardized treatment protocols", "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0059", "M0001", "M0002" ] } ], "costMeasures": [ { "category": "cost", "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "MSPB_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0057", "G0059", "M0003", "M0004" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. 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The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0001", "clinicalTopic": "Oncology and Hematology", "title": "Advancing Cancer Care", "description": "The Advancing Cancer Care MVP focuses on the clinical theme of providing fundamental treatment and management of cancer care. 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{ "code": "99309", "placesOfServiceExclusions": [ "23" ] }, { "code": "99310", "placesOfServiceExclusions": [ "23" ] }, { "code": "99341", "placesOfServiceExclusions": [ "23" ] }, { "code": "99342", "placesOfServiceExclusions": [ "23" ] }, { "code": "99344", "placesOfServiceExclusions": [ "23" ] }, { "code": "99345", "placesOfServiceExclusions": [ "23" ] }, { "code": "99347", "placesOfServiceExclusions": [ "23" ] }, { "code": "99348", "placesOfServiceExclusions": [ "23" ] }, { "code": "99349", "placesOfServiceExclusions": [ "23" ] }, { "code": "99350", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0402", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0438", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0439", "placesOfServiceExclusions": [ "23" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9692" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { 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{ "code": "99213", "placesOfServiceExclusions": [ "12" ] }, { "code": "99214", "placesOfServiceExclusions": [ "12" ] }, { "code": "99215", "placesOfServiceExclusions": [ "12" ] }, { "code": "99304", "placesOfServiceExclusions": [ "12" ] }, { "code": "99305", "placesOfServiceExclusions": [ "12" ] }, { "code": "99306", "placesOfServiceExclusions": [ "12" ] }, { "code": "99307", "placesOfServiceExclusions": [ "12" ] }, { "code": "99308", "placesOfServiceExclusions": [ "12" ] }, { "code": "99309", "placesOfServiceExclusions": [ "12" ] }, { "code": "99310", "placesOfServiceExclusions": [ "12" ] }, { "code": "99315", "placesOfServiceExclusions": [ "12" ] }, { "code": "99316", "placesOfServiceExclusions": [ "12" ] }, { "code": "99341", "placesOfServiceExclusions": [ "12" ] }, { "code": "99342", "placesOfServiceExclusions": [ "12" ] }, { "code": "99344", "placesOfServiceExclusions": [ "12" ] }, { "code": "99345", "placesOfServiceExclusions": [ "12" ] }, { "code": "99347", 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"F30.13" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F30.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F30.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F30.4" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F30.8" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F30.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.10" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.11" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.12" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.13" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.30" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.31" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.32" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.4" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.5" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.60" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.61" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.62" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.63" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.64" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.70" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.71" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.72" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.73" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.74" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.75" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.76" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.77" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.78" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F31.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.4" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.5" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F32.A" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.40" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.41" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.42" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.8" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F33.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.21" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.23" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O90.6" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.340" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.341" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.342" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.343" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.345" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9717" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8431" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8510" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8432" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8511" } ] } ] }, { "title": "Oncology: Medical and Radiation - Pain Intensity Quantified", "eMeasureId": "CMS157v11", "nqfEMeasureId": "0384e", "nqfId": "0384", "measureId": "143", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_143_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms157v11" }, "eMeasureUuid": "2c928084-7b7e-655a-017b-88e5bfb80591", "strata": [ { "name": "Chemotherapy", "description": "Visits for patients with a diagnosis of cancer who are currently receiving chemotherapy", "eMeasureUuids": { "initialPopulationUuid": "0F15C056-2D9F-4B90-A97F-14C34E6AD194", "denominatorUuid": "D54AC8FB-CBA1-4569-9189-7EBFAA66574D", "numeratorUuid": "151395B6-5CD8-4DB5-B86F-8D3DF5100C83" } }, { "name": "RadiationTherapy", "description": "Visits for patients with a diagnosis of cancer who are currently receiving radiation therapy", "eMeasureUuids": { "initialPopulationUuid": "3BC00F94-27F6-45F2-90AC-E47D1BE70A1A", "denominatorUuid": "BD5FB04B-8A49-4488-96B0-6A14BC904E39", "numeratorUuid": "F6B603E8-D49B-4C4D-8AA3-3073626B7A59" } } ] }, { "title": "Oncology: Medical and Radiation - Plan of Care for Pain", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0383", "measureId": "144", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_144_MIPSCQM.pdf" } }, { "title": "CAHPS for MIPS Clinician/Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureId": "321", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "cahps", "allowedPrograms": [ "mips", "pcf", "app1", "G0056", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": { "default": "https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2496/CAHPS%20for%20MIPS%20Survey%20QAG%20V2023.pdf" } }, { "title": "Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "measureId": "450", "description": "Percentage of female patients aged 18 to 70 with stage I (T1c) - III HER2 positive breast cancer for whom appropriate treatment is initiated.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_450_MIPSCQM.pdf" } }, { "title": "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", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1859", "measureId": "451", "description": "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.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_451_MIPSCQM.pdf" } }, { "title": "Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1860", "measureId": "452", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_452_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0210", "measureId": "453", "description": "Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_453_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureId": "457", "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_457_MIPSCQM.pdf" } }, { "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "eMeasureId": "CMS645v6", "nqfEMeasureId": null, "nqfId": null, "measureId": "462", "description": "Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.", "measureType": "process", "isHighPriority": false, "primarySteward": "Oregon Urology Institute", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "endocrinology", "oncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms645v6" }, "eMeasureUuid": "2c928082-7d0a-17c1-017d-0a2f702d00a4", "strata": [ { "description": "Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment", "eMeasureUuids": { "initialPopulationUuid": "A63A2F2D-81BC-4905-800A-195FC31797FE", "denominatorUuid": "7723BDB0-95DB-4430-A1A1-8B164E777E88", "numeratorUuid": "5EC744C6-2ABB-4E81-AEEC-6310E081EDC9", "denominatorExceptionUuid": "2091C83F-1866-4797-9858-877986C576F7" } } ] }, { "measureId": "PIMSH2", "title": "Oncology: Utilization of GCSF in Metastatic Colorectal Cancer", "description": "Percentage of Stage 4 colon/rectal cancer patients receiving any white cell growth factors with chemotherapy", "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "firstPerformanceYear": 2018, "allowedVendors": [ "8794712" ], "allowedPrograms": [ "mips", "pcf", "M0001" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002" ] }, { "category": "ia", "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "description": "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.", "measureId": "IA_BE_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002" ] }, { "category": "ia", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "measureId": "IA_BE_24", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", "measureId": "IA_CC_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Patient Navigator Program", "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", "measureId": "IA_CC_17", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "M0001" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "measureId": "IA_PM_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "M0001", "M0002" ] }, { "category": "ia", "title": "Implementation of episodic care management practice improvements", "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or• Managing care intensively through new diagnoses, injuries and exacerbations of illness.", "measureId": "IA_PM_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0054", "M0001" ] }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0053", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Advance Care Planning", "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", "measureId": "IA_PM_21", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of decision support and standardized treatment protocols", "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0059", "M0001", "M0002" ] } ], "costMeasures": [ { "category": "cost", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "G0056", "M0001", "M0005", "M0002" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0005", "clinicalTopic": "Preventive Care", "title": "Promoting Wellness", "description": "The Promoting Wellness MVP focuses on the clinical theme of promoting quality care for patients in order to reduce the risk of diseases, disabilities, and death.", "specialtiesMostApplicableTo": [ "Preventive Medicine", "Internal Medicine", "Family Medicine", "Geriatrics" ], "clinicalTopics": "Preventive Care", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureId": "039", "description": "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.", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_039_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_039_MIPSCQM.pdf" }, "eligibilityOptions": [ { "maxAge": 85, "minAge": 65, "optionGroup": "00", "procedureCodes": [ { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": 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{ "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F34.89" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.21" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F43.23" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.0" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "F53.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O90.6" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.340" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.341" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.342" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.343" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "O99.345" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9717" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8431" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8510" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8432" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8511" } ] } ] }, { "title": "Preventive Care 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"code": "92523" }, { "code": "92524" }, { "code": "92540" }, { "code": "92557" }, { "code": "92625" }, { "code": "96156" }, { "code": "96158" }, { "code": "97161" }, { "code": "97162" }, { "code": "97163" }, { "code": "97165" }, { "code": "97166" }, { "code": "97167" }, { "code": "97168" }, { "code": "97802" }, { "code": "97803" }, { "code": "97804" }, { "code": "99024" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "99401" }, { "code": "99402" }, { "code": "99403" }, { "code": "99404" }, { "code": "99411" }, { "code": "99412" }, { "code": "99429" }, { "code": "G0270" }, { "code": "G0271" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "M1159" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9902" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9903" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9905" } ] }, { "optionGroup": "01", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "M1159" } ] }, { "optionGroup": "01", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9902" }, { "code": "G9906" } ] }, { "optionGroup": "01", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9902" }, { "code": "G9908" } ] }, { "optionGroup": "02", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "M1159" } ] }, { "optionGroup": "02", "optionType": "performanceMet", "qualityCodes": [ { "code": "1036F" } ] }, { "optionGroup": "02", "optionType": "performanceMet", "qualityCodes": [ { "code": "G0030" } ] }, { "optionGroup": "02", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G0029" } ] } ] }, { "title": "Cervical Cancer Screening", "eMeasureId": "CMS124v11", "nqfEMeasureId": null, "nqfId": null, "measureId": "309", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed within the last 3 years* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms124v11" }, "eMeasureUuid": "2c928082-7a14-d92c-017a-62320c8a1b95", "strata": [ { "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:\n* Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test\n\n* Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test", "eMeasureUuids": { "initialPopulationUuid": "0C07C013-5032-4643-BC28-A4CDAE340F84", "denominatorUuid": "3AF858F0-A8E4-4E32-89CC-CC6A4CA8A160", "numeratorUuid": "4BD54EB9-78DC-4402-9E2F-55B67A49DB80", "denominatorExclusionUuid": "E82D67AB-A1EC-401D-8513-9DC56E5BC05D" } } ] }, { "title": "Chlamydia Screening for Women", "eMeasureId": "CMS153v11", "nqfEMeasureId": null, "nqfId": null, "measureId": "310", "description": "Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms153v11" }, "eMeasureUuid": "2c928082-7a14-d92c-017a-a185ed852f11", "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "8C114CFB-77B8-483E-B557-5798117AA0D2", "denominatorUuid": "DD94450E-004B-4FCB-BA3B-2B6052916921", "numeratorUuid": "DA23B2AF-A0BF-4D9B-9727-511E9EAB55EE", "denominatorExclusionUuid": "3D0BE476-5E5A-4DDE-83CC-C92D1BF6674B", "strata": [ "4C729435-5A08-4265-9BED-801E013ED1E2", "7DEB2D54-2B49-4CC6-A29C-6EB2044040FE" ] } } ] }, { "title": "CAHPS for MIPS Clinician/Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureId": "321", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "cahps", "allowedPrograms": [ "mips", "pcf", "app1", "G0056", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": { "default": "https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2496/CAHPS%20for%20MIPS%20Survey%20QAG%20V2023.pdf" } }, { "title": "One-Time Screening for Hepatitis C Virus (HCV) for all Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "400", "description": "Percentage of patients age >= 18 years who received one-time screening for hepatitis C virus (HCV) infection.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_400_MIPSCQM.pdf" } }, { "title": "Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2152", "measureId": "431", "description": "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 12 months AND who received brief counseling if identified as an unhealthy alcohol user.", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "obstetricsGynecology", "oncology", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "urgentCare", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_431_MIPSCQM.pdf" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "screened", "description": "Patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method" }, { "name": "overall", "description": "Patients aged 18 years and older who were identified as unhealthy alcohol users who received brief counseling" }, { "name": "combinedPopulations", "description": "Patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method and, if identified as unhealthy alcohol users received brief counseling, or were not identified as unhealthy alcohol users" } ] }, { "title": "HIV Screening", "eMeasureId": "CMS349v5", "nqfEMeasureId": null, "nqfId": null, "measureId": "475", "description": "Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for Human immunodeficiency virus (HIV).", "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Disease Control and Prevention", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms349v5" }, "eMeasureUuid": "2c928082-79c7-5ccc-0179-e7314f850909", "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "9129F55B-3A36-4E46-8438-03118FBBE8F3", "denominatorUuid": "19B8D19D-369E-4E2D-9C1A-720EB41EEB90", "numeratorUuid": "93B7A884-9D74-45B7-9FA5-F980DC3A46E9", "denominatorExclusionUuid": "0C0B2EE5-4412-4DA4-AA7B-F95184A5DAE6" } } ] }, { "title": "Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3568", "measureId": "483", "description": "The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "The American Board of Family Medicine", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "nonProportion", "allowedPrograms": [ "mips", "pcf", "G0056", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_483_MIPSCQM.pdf" } }, { "title": "Adult Immunization Status", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureId": "493", "description": "Percentage of patients 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; and pneumococcal.", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "endocrinology", "familyMedicine", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "obstetricsGynecology", "oncology", "otolaryngology", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_493_MIPSCQM.pdf" }, "overallAlgorithm": "weightedAverage", "strata": [ { "name": "influenza", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period" }, { "name": "Tdap", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who received at least 1 tetanus and diphtheria (Td) vaccine or 1 tetanus, diphtheria, and pertussis (Tdap) vaccine between 9 years prior to the the encounter and the end of the measurement period" }, { "name": "herpesZoster", "description": "Percentage of patients (50 years of age and older on the date of the encounter) who received at least 1 dose of the herpes zoster live vaccine or 2 doses of the herpes zoster recombinant vaccine anytime on or after the patients’ 50th birthday" }, { "name": "pneumococcal", "description": "Percentage of patients (66 years of age or older on the date of the encounter) who were administered any pneumococcal conjugate vaccine or polysaccharide vaccine, on or after their 60th birthday and before the end of the measurement period" } ] } ], "iaMeasures": [ { "category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0058", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health", "description": "Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:\r\n• Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or \r\n• Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or\r\n• Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. \r\n\r\nDrivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.", "measureId": "IA_AHE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "G0057", "M0005" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002" ] }, { "category": "ia", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "measureId": "IA_BE_12", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0055", "G0058", "M0005" ] }, { "category": "ia", "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients", "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.", "measureId": "IA_BMH_9", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "M0005" ] }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0057", "G0059", "M0005", "M0002" ] }, { "category": "ia", "title": "Practice Improvements to Align with OpenNotes Principles", "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", "measureId": "IA_CC_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0058", "M0005", "M0002" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regular review practices in place on targeted patient population needs", "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "G0056", "M0005" ] }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0053", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", "description": "Adopt a formal model for quality improvement and create a culture in which all staff, including leadership, actively participates in improvement activities that could include one or more of the following, such as:\n• Participation in multisource feedback; \n• Train all staff in quality improvement methods;\n• Integrate practice change/quality improvement into staff duties;\n• Engage all staff in identifying and testing practices changes;\n• Designate regular team meetings to review data and plan improvement cycles;\n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;\n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;\n• Participation in Bridges to Excellence;\n• Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_PSPA_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0056", "G0057", "M0005" ] } ], "costMeasures": [ { "category": "cost", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "G0056", "M0001", "M0005", "M0002" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", 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"mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { 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"category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0058", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in 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The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", "measureId": "IA_BE_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002" ] }, { "category": "ia", "title": "Engage Patients and Families to Guide Improvement in the System of Care", "description": "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.", "measureId": "IA_BE_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "M0002" ] }, { "category": "ia", "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "description": "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.", "measureId": "IA_BE_15", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002" ] }, { "category": "ia", "title": "Promote Self-management in Usual Care", "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", "measureId": "IA_BE_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0056", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of improvements that contribute to more timely communication of test results", "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", "measureId": "IA_CC_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0057", "G0059", "M0005", "M0002" ] }, { "category": "ia", "title": "Practice Improvements to Align with OpenNotes Principles", "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", "measureId": "IA_CC_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "G0054", "G0056", "G0058", "M0005", "M0002" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regular review practices in place on targeted patient population needs", "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "measureId": "IA_PM_14", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0055", "G0056", "M0001", "M0002" ] }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0053", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of decision support and standardized treatment protocols", "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "G0059", "M0001", "M0002" ] } ], "costMeasures": [ { "category": "cost", "title": "Acute Kidney Injury Requiring New Inpatient Dialysis", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive their first inpatient dialysis service for acute kidney injury during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "measureId": "COST_AKID_1", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-aki-new-hd.pdf" }, "allowedPrograms": [ "mips", "app1", "M0002" ] }, { "category": "cost", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "TPCC_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "G0056", "M0001", "M0005", "M0002" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0003", "clinicalTopic": "Episodic neurological conditions", "title": "Optimal Care for Patients with Episodic Neurological Conditions", "description": "The Optimal Care for Patients with Episodic Neurological Conditions MVP focuses on the clinical theme of promoting quality care for patients suffering from episodic neurological conditions.", "specialtiesMostApplicableTo": [ "Neurology" ], "clinicalTopics": "Episodic neurological conditions", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Advance Care Plan", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureId": "047", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "G0056", "M0001", "M0002", "M0003", "M0004" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" }, "eligibilityOptions": [ { "minAge": 65, "optionGroup": "00", "procedureCodes": [ { "code": "90791", "placesOfServiceExclusions": [ "23" ] }, { "code": "90832", "placesOfServiceExclusions": [ "23" ] }, { "code": "90834", "placesOfServiceExclusions": [ "23" ] }, { "code": "90837", "placesOfServiceExclusions": [ "23" ] }, { "code": "90845", "placesOfServiceExclusions": [ "23" ] }, { "code": "90846", "placesOfServiceExclusions": [ "23" ] }, { "code": "90847", "placesOfServiceExclusions": [ "23" ] }, { "code": "99202", "placesOfServiceExclusions": [ "23" ] }, { "code": "99203", "placesOfServiceExclusions": [ "23" ] }, { "code": "99204", "placesOfServiceExclusions": [ "23" ] }, { "code": "99205", "placesOfServiceExclusions": [ "23" ] }, { "code": "99212", "placesOfServiceExclusions": [ "23" ] }, { "code": "99213", "placesOfServiceExclusions": [ "23" ] }, { "code": "99214", "placesOfServiceExclusions": [ "23" ] }, { "code": "99215", "placesOfServiceExclusions": [ "23" ] }, { "code": "99221", "placesOfServiceExclusions": [ "23" ] }, { "code": "99222", "placesOfServiceExclusions": [ "23" ] }, { "code": "99223", "placesOfServiceExclusions": [ "23" ] }, { "code": "99231", "placesOfServiceExclusions": [ "23" ] }, { "code": "99232", "placesOfServiceExclusions": [ "23" ] }, { "code": "99233", "placesOfServiceExclusions": [ "23" ] }, { "code": "99234", "placesOfServiceExclusions": [ "23" ] }, { "code": "99235", "placesOfServiceExclusions": [ "23" ] }, { "code": "99236", "placesOfServiceExclusions": [ "23" ] }, { "code": "99291", "placesOfServiceExclusions": [ "23" ] }, { "code": "99304", "placesOfServiceExclusions": [ "23" ] }, { "code": "99305", "placesOfServiceExclusions": [ "23" ] }, { "code": "99306", "placesOfServiceExclusions": [ "23" ] }, { "code": "99307", "placesOfServiceExclusions": [ "23" ] }, { "code": "99308", "placesOfServiceExclusions": [ "23" ] }, { "code": "99309", "placesOfServiceExclusions": [ "23" ] }, { "code": "99310", "placesOfServiceExclusions": [ "23" ] }, { "code": "99341", "placesOfServiceExclusions": [ "23" ] }, { "code": "99342", "placesOfServiceExclusions": [ "23" ] }, { "code": "99344", "placesOfServiceExclusions": [ "23" ] }, { "code": "99345", "placesOfServiceExclusions": [ "23" ] }, { "code": "99347", "placesOfServiceExclusions": [ "23" ] }, { "code": "99348", "placesOfServiceExclusions": [ "23" ] }, { "code": "99349", "placesOfServiceExclusions": [ "23" ] }, { "code": "99350", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0402", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0438", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0439", "placesOfServiceExclusions": [ "23" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9692" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1123F" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1124F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "1123F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Documentation of Current Medications in the Medical Record", "eMeasureId": "CMS68v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "130", "description": "Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid 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"pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_130_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms068v12" }, "eMeasureUuid": "2c928082-7c31-8117-017c-9eacd82c2183", "strata": [ { "description": "Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter", "eMeasureUuids": { "initialPopulationUuid": "972EBD00-B885-4E74-8033-B2F14671CCEF", "denominatorUuid": "1959AB01-1DAF-4D59-94C9-D11DE2F515C9", "numeratorUuid": "5E7C9BEE-CC15-42B5-A34E-F8D813CD303E", "denominatorExceptionUuid": "65C83FE7-CFAE-4CDE-B49D-6C78D5D780C5" } } ] }, { "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "268", "description": "Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_268_MIPSCQM.pdf" } }, { "title": "Overuse of Imaging for the Evaluation of Primary Headache", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "419", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_419_MIPSCQM.pdf" } }, { "measureId": "AAN22", "title": "Quality of Life Outcome for Patients with Neurologic Conditions", "description": "Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.", "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003", "M0004" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN29", "title": "Comprehensive Epilepsy Care Center Referral or Discussion for Patients with Epilepsy", "description": "Percentage of patients who were referred or had a discussion of evaluation at a comprehensive epilepsy care center.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2021, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN30", "title": "Migraine Preventive Therapy Management", "description": "Percentage of patients aged 6 years and older with a diagnosis of migraine whose migraine frequency is greater than or equal to 6 days per month/4 attacks per month who were managed with an evidence-based preventive migraine therapy, including therapies prescribed by another clinician.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2021, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN31", "title": "Acute Treatment Prescribed for Cluster Headache", "description": "Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed an acute treatment, including treatments prescribed by a different clinician.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2021, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN32", "title": "Preventive Treatment Prescribed for Cluster Headache", "description": "Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed short-term and/or long-term preventive treatment, including treatments prescribed by a different clinician.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2021, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN5", "title": "Medication Prescribed For Acute Migraine Attack", "description": "Percentage of patients age 6 years and older with a diagnosis of migraine who were prescribed a guideline recommended or FDA approved/cleared treatment for acute migraine attacks within the measurement period.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2016, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0058", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Promote Self-management in Usual Care", "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", "measureId": "IA_BE_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0056", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "measureId": "IA_BE_24", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Depression screening", "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic Health Record Enhancements for BH data capture", "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", "measureId": "IA_BMH_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", "measureId": "IA_CC_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of telehealth services that expand practice access", "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", "measureId": "IA_EPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regular review practices in place on targeted patient population needs", "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0053", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Advance Care Planning", "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", "measureId": "IA_PM_21", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of fall screening and assessment programs", "description": "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).", "measureId": "IA_PSPA_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "M0003", "M0004" ] } ], "costMeasures": [ { "category": "cost", "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "MSPB_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0057", "G0059", "M0003", "M0004" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group 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"measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0004", "clinicalTopic": "Cognitive-based neurological disorders", "title": "Supportive Care for Neurodegenerative Conditions", "description": "The Supportive Care for Neurodegenerative Conditions MVP focuses on the clinical theme of promoting quality care for patients with cognitive-based neurological disorders such as dementia, Parkinson’s Disease (PD), and Amyotrophic Lateral Sclerosis (ALS).", "specialtiesMostApplicableTo": [ "Neurology" ], "clinicalTopics": "Cognitive-based neurological disorders", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Advance Care Plan", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureId": "047", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "G0056", "M0001", "M0002", "M0003", "M0004" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" }, "eligibilityOptions": [ { "minAge": 65, "optionGroup": "00", "procedureCodes": [ { "code": "90791", "placesOfServiceExclusions": [ "23" ] }, { "code": "90832", "placesOfServiceExclusions": [ "23" ] }, { "code": "90834", "placesOfServiceExclusions": [ "23" ] }, { "code": "90837", "placesOfServiceExclusions": [ "23" ] }, { "code": "90845", "placesOfServiceExclusions": [ "23" ] }, { "code": "90846", "placesOfServiceExclusions": [ "23" ] }, { "code": "90847", "placesOfServiceExclusions": [ "23" ] }, { "code": "99202", "placesOfServiceExclusions": [ "23" ] }, { "code": "99203", "placesOfServiceExclusions": [ "23" ] }, { "code": "99204", "placesOfServiceExclusions": [ "23" ] }, { "code": "99205", "placesOfServiceExclusions": [ "23" ] }, { "code": "99212", "placesOfServiceExclusions": [ "23" ] }, { "code": "99213", "placesOfServiceExclusions": [ "23" ] }, { "code": "99214", "placesOfServiceExclusions": [ "23" ] }, { "code": "99215", "placesOfServiceExclusions": [ "23" ] }, { "code": "99221", "placesOfServiceExclusions": [ "23" ] }, { "code": "99222", "placesOfServiceExclusions": [ "23" ] }, { "code": "99223", "placesOfServiceExclusions": [ "23" ] }, { "code": "99231", "placesOfServiceExclusions": [ "23" ] }, { "code": "99232", "placesOfServiceExclusions": [ "23" ] }, { "code": "99233", "placesOfServiceExclusions": [ "23" ] }, { "code": "99234", "placesOfServiceExclusions": [ "23" ] }, { "code": "99235", "placesOfServiceExclusions": [ "23" ] }, { "code": "99236", "placesOfServiceExclusions": [ "23" ] }, { "code": "99291", "placesOfServiceExclusions": [ "23" ] }, { "code": "99304", "placesOfServiceExclusions": [ "23" ] }, { "code": "99305", "placesOfServiceExclusions": [ "23" ] }, { "code": "99306", "placesOfServiceExclusions": [ "23" ] }, { "code": "99307", "placesOfServiceExclusions": [ "23" ] }, { "code": "99308", "placesOfServiceExclusions": [ "23" ] }, { "code": "99309", "placesOfServiceExclusions": [ "23" ] }, { "code": "99310", "placesOfServiceExclusions": [ "23" ] }, { "code": "99341", "placesOfServiceExclusions": [ "23" ] }, { "code": "99342", "placesOfServiceExclusions": [ "23" ] }, { "code": "99344", "placesOfServiceExclusions": [ "23" ] }, { "code": "99345", "placesOfServiceExclusions": [ "23" ] }, { "code": "99347", "placesOfServiceExclusions": [ "23" ] }, { "code": "99348", "placesOfServiceExclusions": [ "23" ] }, { "code": "99349", "placesOfServiceExclusions": [ "23" ] }, { "code": "99350", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0402", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0438", "placesOfServiceExclusions": [ "23" ] }, { "code": "G0439", "placesOfServiceExclusions": [ "23" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9692" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1123F" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "1124F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "1123F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Use of High-Risk Medications in Older Adults", "eMeasureId": "CMS156v11", "nqfEMeasureId": null, "nqfId": "0022", "measureId": "238", "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "allowedPrograms": [ "mips", "pcf", "G0055", "M0004" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "geriatrics", "internalMedicine", "oncology", "ophthalmology", "otolaryngology", "pulmonology", "rheumatology", "skilledNursingFacility", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_238_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms156v11" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "eMeasureUuids": { "initialPopulationUuid": "064940DC-3F04-4B31-88CA-367BE20AC510", "denominatorUuid": "CD3CCAD3-3E90-4094-9987-9A9D2A5D574D", "numeratorUuid": "E384D9B0-6AD6-45BC-B562-A57E46FC1E90", "denominatorExclusionUuid": "CEC58D2D-4525-45B8-B320-FFB35B654DA8" }, "name": "overall" }, { "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.", "eMeasureUuids": { "initialPopulationUuid": "5E28FE53-02D9-4A14-9721-74729FBF2F73", "denominatorUuid": "5BE6C6E2-64FA-49D5-8D2E-B977E2AB62A7", "numeratorUuid": "5577FDAE-5153-4B75-9B85-59CEF09CFC82", "numeratorExclusionUuid": "C813AAC7-6D05-45D0-838D-467A837ECEC0", "denominatorExclusionUuid": "82D62AA5-015B-4256-AF2B-C43D52622EFB" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "2B4CFB1B-43D2-4ABA-AE55-CCF174208A3B", "denominatorUuid": "725E725B-DF32-429A-BAEE-444AD4CE5FC7", "numeratorUuid": "35C1118F-EBF8-470F-8B70-150CB04435AA", "denominatorExclusionUuid": "AEA06864-DA4F-4ECD-93EC-BA6B94930337" }, "name": "totalRate" } ], "eMeasureUuid": "2c928084-808a-9589-0180-d74bf7b7164d" }, { "title": "Dementia: Cognitive Assessment", "eMeasureId": "CMS149v11", "nqfEMeasureId": "2872e", "nqfId": null, "measureId": "281", "description": "Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms149v11" }, "eMeasureUuid": "2c928082-7a14-d92c-017a-5d9c93c61797", "strata": [ { "description": "Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period", "eMeasureUuids": { "initialPopulationUuid": "B131923B-75CF-4D85-B4C9-FD412CC0036D", "denominatorUuid": "530B1477-EEA8-4383-AE24-06062643583B", "numeratorUuid": "FCA90502-9BED-48C7-B08F-F0719338ACCE", "denominatorExceptionUuid": "4BADB805-F737-4423-8DC3-DDDCF071244F" } } ] }, { "title": "Dementia: Functional Status Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "282", "description": "Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_282_MIPSCQM.pdf" } }, { "title": "Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "286", "description": "Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_286_MIPSCQM.pdf" } }, { "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "288", "description": "Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_288_MIPSCQM.pdf" } }, { "title": "Assessment of Mood Disorders and Psychosis for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "290", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for depression, anxiety, apathy, AND psychosis once during the measurement period.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [ "registry" ], "isClinicalGuidelineChanged": false, "isIcdImpacted": true, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_290_MIPSCQM.pdf" } }, { "title": "Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "291", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period.", "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [ "registry" ], "isClinicalGuidelineChanged": false, "isIcdImpacted": true, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_291_MIPSCQM.pdf" } }, { "title": "Rehabilitative Therapy Referral for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "293", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [ "registry" ], "isClinicalGuidelineChanged": false, "isIcdImpacted": true, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_293_MIPSCQM.pdf" } }, { "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "386", "description": "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.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_386_MIPSCQM.pdf" } }, { "measureId": "AAN22", "title": "Quality of Life Outcome for Patients with Neurologic Conditions", "description": "Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.", "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2019, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0003", "M0004" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN34", "title": "Patient reported falls and plan of care", "description": "Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit", "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2021, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0004" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "AAN9", "title": "Querying and Follow-Up About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease", "description": "Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified, patient had appropriate follow-up.", "nqfId": null, "measureType": "process", "isHighPriority": false, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Axon Registry", "firstPerformanceYear": 2017, "allowedVendors": [ "8933551" ], "allowedPrograms": [ "mips", "pcf", "M0004" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "measureId": "IA_AHE_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0058", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Engagement of patients through implementation of improvements in patient portal", "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", "measureId": "IA_BE_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0056", "G0057", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Promote Self-management in Usual Care", "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", "measureId": "IA_BE_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0056", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "measureId": "IA_BE_24", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "G0054", "G0055", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Depression screening", "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_4", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic Health Record Enhancements for BH data capture", "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", "measureId": "IA_BMH_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", "measureId": "IA_CC_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "G0056", "G0059", "M0001", "M0005", "M0003", "M0004" ] }, { "category": "ia", "title": "Use of telehealth services that expand practice access", "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", "measureId": "IA_EPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "G0053", "M0003", "M0004" ] }, { "category": "ia", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Regular review practices in place on targeted patient population needs", "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "measureId": "IA_PM_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "G0053", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "ia", "title": "Advance Care Planning", "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", "measureId": "IA_PM_21", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Implementation of fall screening and assessment programs", "description": "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).", "measureId": "IA_PSPA_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "M0003", "M0004" ] } ], "costMeasures": [ { "category": "cost", "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "measureId": "MSPB_1", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0057", "G0059", "M0003", "M0004" ] } ], "foundationPiMeasures": [ { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2", "PI_EP_2_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "measureSpecification": { "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under TEFCA", "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "isRequired": true, "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2", "title": "Syndromic Surveillance Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3", "title": "Electronic Case Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PROD", "title": "Immunization Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_1_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PRE", "title": "Syndromic Surveillance Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_2_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PRE", "title": "Electronic Case Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [ "PI_PHCDRR_3_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_4_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PROD" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "substitutes": [ "PI_PHCDRR_5_PRE" ], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_EP_2_EX_3", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician for whom querying a PDMP would impose an excessive workflow or cost burden prior to the start of the performance period they select in CY 2023.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_2", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_1", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "substitutes": [], "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "objective": "attestation", "isBonus": false, "reportingCategory": null, "substitutes": [], "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "preprod": [] } ], "foundationQualityMeasures": [ { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "484", "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] } ]