[ { "mvpId": "G0053", "clinicalTopic": "Rheumatology", "title": "Advancing Rheumatology Patient Care", "description": "The Advancing Rheumatology Patient Care MVP focuses on the clinical theme of providing fundamental treatment and management of rheumatological conditions.", "specialtiesMostApplicableTo": [ "Rheumatology" ], "clinicalTopics": "Rheumatology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Documentation of Current Medications in the Medical Record", "eMeasureId": "CMS68v13", "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 Services", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0003", "M1368" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_130_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0068v13" }, "eMeasureUuid": "2c928082-86db-6718-0187-0b4977140ad5", "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": "018818BA-BAEE-4F63-B345-0ECF647B7580", "denominatorUuid": "F0F5F489-3AE0-4128-A3D3-7427B5F333A4", "numeratorUuid": "A65C0BE1-19D2-40E5-910D-9B95960C4B6C", "denominatorExceptionUuid": "294E02A5-FBA5-4863-B215-D25B396C3E79" } } ] }, { "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "eMeasureId": "CMS2v13", "nqfEMeasureId": null, "nqfId": null, "measureId": "134", "description": "Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.", "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", "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "emergencyMedicine", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_134_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_134_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0002v13" }, "eMeasureUuid": "2c928083-8651-08a3-0186-c82995a91d28", "strata": [ { "description": "Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "AD83208C-1313-401E-BB62-ABCCE0982B49", "denominatorUuid": "696066C7-C558-4849-A325-A3CDDB58CF8F", "numeratorUuid": "E2557B71-1B97-413F-BE26-2B037E4D590B", "denominatorExceptionUuid": "FBA7B9D9-8588-4CB2-AB72-642CBD980334", "denominatorExclusionUuid": "E52F7FAE-96D9-417A-8538-6E3DB4A31D7A" } } ], "eligibilityOptions": [ { "diagnosisExclusionCodes": [ "F30.10", "F30.11", "F30.12", "F30.13", "F30.2", "F30.3", "F30.4", "F30.8", "F30.9", "F31.0", "F31.10", "F31.11", "F31.12", "F31.13", "F31.2", "F31.30", "F31.31", "F31.32", "F31.4", "F31.5", "F31.60", "F31.61", "F31.62", "F31.63", "F31.64", "F31.70", "F31.71", "F31.72", "F31.73", "F31.74", "F31.75", "F31.76", "F31.77", "F31.78", "F31.81", "F31.89", "F31.9" ], "minAge": 12, "optionGroup": "00", "procedureCodes": [ { "code": "59400" }, { "code": "59510" }, { "code": "59610" }, { "code": "59618" }, { "code": "90791" }, { "code": "90792" }, { "code": "90832" }, { "code": "90834" }, { "code": "90837" }, { "code": "92622" }, { "code": "92625" }, { "code": "96105" }, { "code": "96110" }, { "code": "96112" }, { "code": "96116" }, { "code": "96125" }, { "code": "96136" }, { "code": "96138" }, { "code": "96156" }, { "code": "96158" }, { "code": "97161" }, { "code": "97162" }, { "code": "97163" }, { "code": "97164" }, { "code": "97165" }, { "code": "97166" }, { "code": "97167" }, { "code": "97802" }, { "code": "97803" }, { "code": "98966" }, { "code": "98967" }, { "code": "98968" }, { "code": "99078" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307" }, { "code": "99308" }, { "code": "99309" }, { "code": "99310" }, { "code": "99315" }, { "code": "99316" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99384" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99394" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "99401" }, { "code": "99402" }, { "code": "99403" }, { "code": "99424" }, { "code": "99441" }, { "code": "99442" }, { "code": "99443" }, { "code": "99483" }, { "code": "99484" }, { "code": "99491" }, { "code": "99492" }, { "code": "99493" }, { "code": "G0101" }, { "code": "G0270" }, { "code": "G0271" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" }, { "code": "G0444" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8433" } ] }, { "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", "companionMeasureId": [], "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/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_180_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0005", "M1366", "M1368" ], "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/2024_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 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" } ] }, { "title": "Gains in Patient Activation Measure (PAM) Scores at 12 Months", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "503", "description": "The Patient Activation Measure (PAM) (Registered Trademark) is a 10- or 13- item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM performance measure (PAM-PM) is the change in score on the PAM from baseline to follow-up measurement.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0055", "M0001", "M0002", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_503_MIPSCQM_Spec_and_Addendum.zip" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period." }, { "name": "6points", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period." } ] }, { "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": [ "3471690", "5598408", "3967247" ], "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": [ "3471690", "5598408", "3967247" ], "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": [ "3471690", "5598408", "3967247" ], "allowedPrograms": [ "mips", "pcf", "G0053" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "UREQA10", "title": "Ankylosing Spondylitis: Controlled Disease Or Improved Disease Function", "description": "Percentage of qualifying visits for patients aged 18 years and older with a diagnosis of ankylosing spondylitis whose most recent BASDAI score is less than 4 OR who were in suboptimal disease control (BASDAI score >= 4.0) and who have seen an improvement by at least one point over the previous BASDAI score within the last 12 months.", "nqfId": null, "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "firstPerformanceYear": 2023, "allowedVendors": [ "1649514" ], "allowedPrograms": [ "mips", "pcf", "G0053" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ], "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [] } ], "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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054" ] }, { "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", "pcf", "app1", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "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", "pcf", "app1", "G0053", "G0055" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0053", "M0001" ] } ], "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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", 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"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": [], 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"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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "neurosurgical" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_413_MIPSCQM.pdf" } }, { "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "eMeasureId": "CMS347v7", "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 performance period:\r\n•\tAll patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR\r\n•\tPatients aged 20 to 75 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\r\n•\tPatients aged 40 to 75 years with a diagnosis of diabetes; OR\r\n•\tPatients aged 40 to 75 with a 10-year ASCVD risk score of ≥ 20 percent.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "M0005" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_438_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0347v7" }, "historic_benchmarks": { "registry": "removed", "electronicHealthRecord": "removed" }, "eMeasureUuid": "2c928082-82cb-a3f5-0182-cc688be40080", "strata": [ { "description": "All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure", "eMeasureUuids": { "initialPopulationUuid": "0B4F91D7-B2F9-48AF-A3ED-9115908DCAFE", "denominatorUuid": "34D89E97-4B99-43BB-97C7-C071F0DF971A", "numeratorUuid": "D7F7EDC4-8930-4656-96C5-818874EDA005", "denominatorExceptionUuid": "01D44136-D906-4907-95C4-08D6CE12621E", "denominatorExclusionUuid": "26B642A2-FA54-4CDD-9777-340A16FCB119" } }, { "description": "Patients aged 20 to 75 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": "45432B7C-8E52-42C9-9901-EBC06AA312EA", "denominatorUuid": "6498FD8C-CC34-4A75-97BB-479ED9C7E7B2", "numeratorUuid": "3768636A-6914-4E99-A1FF-86985EA906CE", "denominatorExceptionUuid": "295A9E4F-F784-4DE5-B228-8094E589B6EB", "denominatorExclusionUuid": "0C5DCCA9-17F2-41FC-9898-2E69F6BD4D52" } }, { "description": "Patients aged 40-75 years with a diagnosis of diabetes", "eMeasureUuids": { "initialPopulationUuid": "A1AB27A9-7C38-44A6-9FD5-4CCAD4015D2F", "denominatorUuid": "B84D1E69-BE12-429B-94BB-C52A6C7C05D1", "numeratorUuid": "AA438B03-6489-404B-B9E1-519A3CBBA075", "denominatorExceptionUuid": "A07A4226-5C2F-46CE-AE94-4DC932D1FC2E", "denominatorExclusionUuid": "DC9CE27C-94EF-4D4D-B2B9-20BB47ECB959" } }, { "description": "Patients aged 40 to 75 with a 10-year ASCVD risk score of >= 20 percent", "eMeasureUuids": { "initialPopulationUuid": "8B574B6B-8D8A-4E82-B1D5-193593C79E03", "denominatorUuid": "DCD01DD8-1B0B-4BDA-A69C-F928346A6B51", "numeratorUuid": "327F02A6-9AB0-4B06-8CD9-EB8805A6E344", "denominatorExceptionUuid": "BD48F0E9-0218-4381-94E1-6A12DF7BDF68", "denominatorExclusionUuid": "B0A97297-2AF3-414F-80A8-8DBA5D14A604" } } ] }, { "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", "companionMeasureId": [], "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/2024_Measure_441_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } } ], "iaMeasures": [ { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "M0001", "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "category": "ia", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults", "description": "Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.", "measureId": "IA_BMH_15", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0054", "M0001" ] }, { "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", "pcf", "app1", "G0054", "G0057", "G0059", "M0002", "M0005" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0055", "M0002", "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", "pcf", "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/2023-12-05-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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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": "CMS135v12", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureId": "005", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "hospitalists", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_005_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0135v12" }, "eMeasureUuid": "2c928082-86db-6718-0186-ec6666280586", "strata": [ { "description": "Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "3BBD33AA-ACDC-4D08-A22D-2B640B3BAC55", "denominatorUuid": "D5EC2146-2734-4AEA-941E-73954FBC0CAC", "numeratorUuid": "91C32273-EEF9-4557-992A-3C5DA994B1A5", "denominatorExceptionUuid": "EED321A6-8960-4A3E-84C8-0E9F06919DC2", "denominatorExclusionUuid": "F269B9AD-04EE-4129-9B20-81DD1B1A0FAA" } } ] }, { "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": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_006_MIPSCQM.pdf" } }, { "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", "eMeasureId": "CMS145v12", "nqfEMeasureId": "0070e", "nqfId": "0070", "measureId": "007", "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 a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker 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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_007_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0145v12" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-622192411e05", "strata": [ { "description": "Patients with left ventricular systolic dysfunction (LVEF <=40%)", "eMeasureUuids": { "initialPopulationUuid": "2E452C4A-C782-4373-AB54-646521DCDDEE", "denominatorUuid": "901D3C9A-DB42-4A92-9E78-2693F6EEDA99", "numeratorUuid": "DBA0383C-B6EE-4ACC-A44F-9A11E0C4C33F", "denominatorExceptionUuid": "223FC84C-A50A-4460-92B5-3808D89FF2C9" } }, { "description": "Patients with a prior (within the past 3 years) myocardial infarction", "eMeasureUuids": { "initialPopulationUuid": "F0F58CC7-7DC0-4BC2-AD55-4B92696A4501", "denominatorUuid": "C0A53EC4-5324-4C8B-B7E1-BA52F9D3D10C", "numeratorUuid": "A3DAC3E6-BAAF-4A42-89E6-8AC8FAA71E68", "denominatorExceptionUuid": "4315CAB0-73F3-4756-A9F2-DDADD376D77E" } } ] }, { "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS144v12", "nqfEMeasureId": "0083e", "nqfId": "0083", "measureId": "008", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "hospitalists", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_008_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0144v12" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-65e9c0061ec1", "strata": [ { "description": "Patients who were prescribed or already taking beta-blocker therapy during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "BC5D30AA-8AA4-4BA6-9FBE-B52D47CAF292", "denominatorUuid": "F2435FA0-0AF1-4A64-BB27-4E7ED13F387B", "numeratorUuid": "D997534A-AF2A-4AEE-9EFC-358EB0273EDB", "denominatorExceptionUuid": "A3ED0DA1-60C2-4D42-BF86-EDEF350CD369", "denominatorExclusionUuid": "C7CFF7D2-0A86-4FB1-BBA7-2A91E65262C8" } } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "M0001", "M0002", "M0003", "M0004", "M0005" ], "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/2024_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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": "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", 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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": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "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/2024_Measure_326_MIPSCQM.pdf" } }, { "title": "Functional Status Assessments for Heart Failure", "eMeasureId": "CMS90v13", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0090v13" }, "eMeasureUuid": "2c928084-8389-524e-0183-c80f9e480dff", "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": "FA9EF028-5532-437D-9125-4187BF72E952", "denominatorUuid": "3BDFDBDD-CEBF-4C34-8AA7-8D65A324F4B1", "numeratorUuid": "91550F78-0296-4B2A-996C-0B9F51B9FAF3", "denominatorExclusionUuid": "CC8028CF-86F0-4930-AB9F-475DA2370A5B" } } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "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/2024_Measure_441_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "title": "Gains in Patient Activation Measure (PAM) Scores at 12 Months", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "503", "description": "The Patient Activation Measure (PAM) (Registered Trademark) is a 10- or 13- item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM performance measure (PAM-PM) is the change in score on the PAM from baseline to follow-up measurement.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0055", "M0001", "M0002", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_503_MIPSCQM_Spec_and_Addendum.zip" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period." }, { "name": "6points", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period." } ] } ], "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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M0005", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "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", "pcf", "app1", "G0053", "G0055" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M1366" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0055", "M0002", "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", "pcf", "app1", "G0055", "M0001", "M1368" ] }, { "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", "pcf", "app1", "G0055" ] }, { "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", "pcf", "app1", "G0055", "G0057", "G0058", "G0059", "M1367" ] } ], "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/2023-12-05-mif-ebcm-op-pci.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055" ] }, { "category": "cost", "title": "Heart Failure", "description": "Patients receiving medical care to manage and treat heart failure. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Heart Failure episode.", "measureId": "COST_HF_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "G0055", "M0005" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-heart-fail-v2.pdf" } }, { "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/2023-12-05-mif-ebcm-stemi-pci-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055" ] }, { "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] }, { "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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0055" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": null } ] }, { "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": "Appropriate Treatment for Upper Respiratory Infection (URI)", "eMeasureId": "CMS154v12", "nqfEMeasureId": null, "nqfId": "0069", "measureId": "065", "description": "Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0057", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "infectiousDisease", "pediatrics", "urgentCare" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_065_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0154v12" }, "eMeasureUuid": "2c928084-8389-524e-0183-c8d7a6700f02", "strata": [ { "description": "URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection", "eMeasureUuids": { "initialPopulationUuid": "83DB196F-463B-4E77-ABC4-7B38F0C60D36", "denominatorUuid": "766AC88F-A02D-42E1-B34C-7BFB2874A824", "numeratorUuid": "EE960FF9-ED6B-49E8-A1CC-D0C93513355B", "denominatorExclusionUuid": "8DABD0C9-3DE6-4221-9F84-0E2EB872075F", "strata": [ "79520F15-07EF-4D9C-BA96-080F356FF328", "B5624EA1-BB69-4366-B65F-2192D2BB7BA7", "C4096D01-6428-4021-8E72-AE255C8874BE" ] } } ] }, { "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", "companionMeasureId": [], "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/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {} }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0057", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_415_MIPSCQM.pdf" } }, { "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "416", "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.", "measureType": "efficiency", "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_416_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "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" ], "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", "1718371" ], "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": [ "5133825", "3471690", "1718371", "4757099", "1725296", "3967247" ], "allowedPrograms": [ "mips", "pcf", "G0057" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "HCPR24", "title": "Appropriate Utilization of Vancomycin for Cellulitis", "description": "Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "firstPerformanceYear": 2022, "allowedVendors": [ "5133825", "1718371", "4757099", "1725296", "8483899" ], "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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "category": "ia", "title": "Promoting Clinician Well-Being", "description": "Develop and implement programs to support clinician well-being and resilience—for example, through relationship-building opportunities, leadership development plans, or creation of a team within a practice to address clinician well-being—using one of the following approaches:•\tCompletion of clinician survey on clinician well-being with subsequent implementation of an improvement plan based on the results of the survey.•\tCompletion of training regarding clinician well-being with subsequent implementation of a plan for improvement.", "measureId": "IA_BMH_12", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "G0057", "M0001", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0057", "G0059", "M0002", "M0005" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0057", "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", "pcf", "app1", "G0057" ] }, { "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", "pcf", "app1", "G0055", "G0057", "G0058", "G0059", "M1367" ] } ], "costMeasures": [ { "category": "cost", "title": "Emergency Medicine", "description": "Patients who have an Emergency Department (ED) during the year.", "measureId": "COST_EDV_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "G0057" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-emergency-v2.pdf" } } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "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/2024_Measure_024_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_024_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "M48.40XA", "M48.41XA", "M48.42XA", "M48.43XA", "M48.44XA", "M48.45XA", "M48.46XA", "M48.47XA", "M48.48XA", "M80.00XA", "M80.011A", "M80.012A", "M80.019A", "M80.021A", "M80.022A", "M80.029A", "M80.031A", "M80.032A", "M80.039A", "M80.041A", "M80.042A", "M80.049A", "M80.051A", "M80.052A", "M80.059A", "M80.061A", "M80.062A", "M80.069A", "M80.071A", "M80.072A", "M80.079A", "M80.08XA", "M80.0AXA", "M80.0B1A", "M80.0B1D", "M80.0B1G", "M80.0B1K", "M80.0B1P", "M80.0B1S", "M80.0B2A", "M80.0B2D", "M80.0B2G", "M80.0B2K", "M80.0B2P", "M80.0B2S", "M80.0B9A", "M80.0B9D", "M80.0B9G", "M80.0B9K", "M80.0B9P", "M80.0B9S", "M80.80XA", "M80.811A", "M80.812A", "M80.819A", "M80.821A", "M80.822A", "M80.829A", "M80.831A", "M80.832A", "M80.839A", "M80.841A", "M80.842A", "M80.849A", "M80.851A", "M80.852A", "M80.859A", "M80.861A", "M80.862A", "M80.869A", 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"modifierExclusions": [ "GQ", "GT", "95", "FQ", "93" ], "placesOfServiceExclusions": [ "02", "10", "12" ] }, { "code": "G0439", "modifierExclusions": [ "GQ", "GT", "95", "FQ", "93" ], "placesOfServiceExclusions": [ "02", "10", "12" ] }, { "code": "G0447", "modifierExclusions": [ "GQ", "GT", "95", "FQ", "93" ], "placesOfServiceExclusions": [ "02", "10", "12" ] }, { "code": "G0473", "modifierExclusions": [ "GQ", "GT", "95", "FQ", "93" ], "placesOfServiceExclusions": [ "02", "10", "12" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G2181" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9716" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9996" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9997" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8417" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8418" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8420" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8419" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8421" } ] } ] }, { "title": "Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "350", "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_350_MIPSCQM.pdf" } }, { "title": "Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "351", "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).", "measureType": "process", "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_351_MIPSCQM.pdf" } }, { "title": "Functional Status Assessment for Total Hip Replacement", "eMeasureId": "CMS56v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "376", "description": "Percentage of patients 19 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 300 – 425 days after the surgery.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0058" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0056v12" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-6bd4e33420bd", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10-Global Health, Hip Disability and Osteoarthritis Outcome Score [HOOS], HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 300 - 425 days after the THA procedure", "eMeasureUuids": { "initialPopulationUuid": "AF4C1C0E-79D7-4693-ACB8-6FACDCEEF0D4", "denominatorUuid": "60759161-5DB6-4E1B-8D07-32A5561AE0C4", "numeratorUuid": "AA9FBD3C-49EC-4A9E-BDD5-65F454BC7416", "denominatorExclusionUuid": "A640731E-3B26-4662-A243-C1BED87544AF" } } ] }, { "title": "Functional Status After Primary Total Knee Replacement", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "470", "description": "For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_470_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M0005", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0058", "G0059" ] }, { "category": "ia", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "measureId": "IA_CC_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "pcf", "app1", "G0058" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M1366" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "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", "pcf", "app1", "G0058" ] }, { "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", "pcf", "app1", "G0055", "G0057", "G0058", "G0059", "M1367" ] } ], "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/2023-12-05-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/2023-12-05-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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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 management.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_477_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "measureId": "ABG44", "title": "Low Flow Inhalational General Anesthesia", "description": "Percentage of patients aged 18 years or older, who undergo an elective procedure lasting 30 minutes or longer requiring inhalational general anesthesia who during the maintenance phase of the anesthetic have a total fresh gas flow less than or equal to 1 L/min (less than or equal to 2 L/min for Sevoflurane).", "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "ABG QCDR in Collaboration with Insight Medical Data Services, LLC", "firstPerformanceYear": 2023, "allowedVendors": [ "5551268", "6169123", "6775913", "9181695", "7418330" ], "allowedPrograms": [ "mips", "pcf", "G0059" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ], "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [] }, { "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 within 60 days of receipt of the survey.\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) in Collaboration with American Society of Anesthesiologists (ASA)", "firstPerformanceYear": 2017, "allowedVendors": [ "5551268", "3471690", "6169123", "6775913", "6704504", "9181695", "4757099", "7418330", "3967247" ], "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": "AQI48a, percentage of surgical patients who receive a survey of their experience with anesthesia care." }, { "name": "overall", "description": "AQI48b, percentage of surgical patients who report a positive experience with anesthesia care." } ] }, { "measureId": "EPREOP31", "title": "Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases", "description": "Percentage of general, neuraxial, or regional anesthesia care cases in which the mean arterial pressure (MAP) fell below 65 mmHg for a cumulative total of 15 minutes or more", "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "isInverse": true, "isRiskAdjusted": true, "primarySteward": "Anesthesia Quality Registry (AQR QCDR) in Collaboration with Anesthesia Quality Institute (AQI) and American Society of Anesthesiologists (ASA)", "firstPerformanceYear": 2020, "allowedVendors": [ "6169123", "6775913", "7418330" ], "allowedPrograms": [ "mips", "pcf", "G0059" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "nonProportion", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "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", "pcf", "app1", "G0059" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M1369" ] }, { "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", "pcf", "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", "pcf", "app1", "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", "pcf", "app1", "G0054", "G0057", "G0059", "M0002", "M0005" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0057", "G0059" ] }, { "category": "ia", "title": "Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.", "description": "Use decision support - ideally platform-agnostic, interoperable clinician decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs. Clinicians should focus on utilizing open-source, freely available, interoperable CDS in completing the requirements of this activity.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "G0059", "M0001", "M0002", "M1370" ] }, { "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", "pcf", "app1", "G0055", "G0057", "G0058", "G0059", "M1367" ] } ], "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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. The measures assess three critical areas: the patient experience of care, end of life care, and appropriate diagnostics along with possible treatment options for different cancer diagnoses.", "specialtiesMostApplicableTo": [ "Oncology", "Hematology" ], "clinicalTopics": "Oncology and Hematology", "hasCahps": true, "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "M0001", "M0002", "M0003", "M0004", "M0005" ], "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/2024_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "eMeasureId": "CMS2v13", "nqfEMeasureId": null, "nqfId": null, "measureId": "134", "description": "Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.", "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", "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "emergencyMedicine", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_134_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_134_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0002v13" }, "eMeasureUuid": "2c928083-8651-08a3-0186-c82995a91d28", "strata": [ { "description": "Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "AD83208C-1313-401E-BB62-ABCCE0982B49", "denominatorUuid": "696066C7-C558-4849-A325-A3CDDB58CF8F", "numeratorUuid": "E2557B71-1B97-413F-BE26-2B037E4D590B", "denominatorExceptionUuid": "FBA7B9D9-8588-4CB2-AB72-642CBD980334", "denominatorExclusionUuid": "E52F7FAE-96D9-417A-8538-6E3DB4A31D7A" } } ], "eligibilityOptions": [ { "diagnosisExclusionCodes": [ "F30.10", "F30.11", "F30.12", "F30.13", "F30.2", "F30.3", "F30.4", "F30.8", "F30.9", "F31.0", "F31.10", "F31.11", "F31.12", "F31.13", "F31.2", "F31.30", "F31.31", "F31.32", "F31.4", "F31.5", "F31.60", "F31.61", "F31.62", "F31.63", "F31.64", "F31.70", "F31.71", "F31.72", "F31.73", "F31.74", "F31.75", "F31.76", "F31.77", "F31.78", "F31.81", "F31.89", "F31.9" ], "minAge": 12, "optionGroup": "00", "procedureCodes": [ { "code": "59400" }, { "code": "59510" }, { "code": "59610" }, { "code": "59618" }, { "code": "90791" }, { "code": "90792" }, { "code": "90832" }, { "code": "90834" }, { "code": "90837" }, { "code": "92622" }, { "code": "92625" }, { "code": "96105" }, { "code": "96110" }, { "code": "96112" }, { "code": "96116" }, { "code": "96125" }, { "code": "96136" }, { "code": "96138" }, { "code": "96156" }, { "code": "96158" }, { "code": "97161" }, { "code": "97162" }, { "code": "97163" }, { "code": "97164" }, { "code": "97165" }, { "code": "97166" }, { "code": "97167" }, { "code": "97802" }, { "code": "97803" }, { "code": "98966" }, { "code": "98967" }, { "code": "98968" }, { "code": "99078" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307" }, { "code": "99308" }, { "code": "99309" }, { "code": "99310" }, { "code": "99315" }, { "code": "99316" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99384" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99394" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "99401" }, { "code": "99402" }, { "code": "99403" }, { "code": "99424" }, { "code": "99441" }, { "code": "99442" }, { "code": "99443" }, { "code": "99483" }, { "code": "99484" }, { "code": "99491" }, { "code": "99492" }, { "code": "99493" }, { "code": "G0101" }, { "code": "G0270" }, { "code": "G0271" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" }, { "code": "G0444" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8433" } ] }, { "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": "CMS157v12", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_143_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0157v12" }, "eMeasureUuid": "2c928084-8389-524e-0183-d1b67f3a1388", "strata": [ { "description": "Visits for patients with a diagnosis of cancer who are currently receiving chemotherapy", "eMeasureUuids": { "initialPopulationUuid": "0271EF2B-26A3-4672-A697-F227D294C5E8", "denominatorUuid": "E0C4BF62-6A49-4CFF-A215-49C1E1D966F1", "numeratorUuid": "DF2CFD3B-1B2E-45C0-A2C3-F048317ECCE6" } }, { "description": "Visits for patients with a diagnosis of cancer who are currently receiving radiation therapy", "eMeasureUuids": { "initialPopulationUuid": "05739862-79A6-4DEC-BD34-0ADE00ED65A8", "denominatorUuid": "5E21A436-94F8-47BD-BD09-C1F94F1C347D", "numeratorUuid": "81010375-6D7E-42D3-89F7-9FD33A231FD8" } } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {} }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_457_MIPSCQM.pdf" } }, { "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "eMeasureId": "CMS645v7", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "endocrinology", "oncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0645v7" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-851958a525c2", "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": "4653DDD0-4E47-46F8-91EC-754DB709FD5B", "denominatorUuid": "7AF6325B-6BE7-4E06-A8EB-3CE504E877A8", "numeratorUuid": "43D18B6F-9887-41EB-B4EC-0A391BAAEE41", "denominatorExceptionUuid": "115003E3-848E-405F-A3FB-AA1B79CE174A" } } ] }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "title": "Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "490", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of cancer, on immune checkpoint inhibitor therapy, and grade 2 or above diarrhea and/or grade 2 or above colitis, who have immune checkpoint inhibitor therapy held and corticosteroids or immunosuppressants prescribed or administered.", "measureType": "process", "isHighPriority": false, "primarySteward": "Society for Immunotherapy of Cancer (SITC)", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_490_MIPSCQM.pdf" } }, { "title": "Gains in Patient Activation Measure (PAM) Scores at 12 Months", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "503", "description": "The Patient Activation Measure (PAM) (Registered Trademark) is a 10- or 13- item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM performance measure (PAM-PM) is the change in score on the PAM from baseline to follow-up measurement.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0055", "M0001", "M0002", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_503_MIPSCQM_Spec_and_Addendum.zip" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period." }, { "name": "6points", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period." } ] }, { "measureId": "PIMSH13", "title": "Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy", "description": "Proportion of stage IV nsNSCLC patients tested for actionable biomarkers and received targeted therapy or chemotherapy based on biomarker results", "nqfId": null, "measureType": "process", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "firstPerformanceYear": 2023, "allowedVendors": [ "8794712", "7037323" ], "allowedPrograms": [ "mips", "pcf", "M0001" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ], "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [] }, { "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", "7037323" ], "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, 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", "pcf", "app1", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "M0001", "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "category": "ia", "title": "Promoting Clinician Well-Being", "description": "Develop and implement programs to support clinician well-being and resilience—for example, through relationship-building opportunities, leadership development plans, or creation of a team within a practice to address clinician well-being—using one of the following approaches:•\tCompletion of clinician survey on clinician well-being with subsequent implementation of an improvement plan based on the results of the survey.•\tCompletion of training regarding clinician well-being with subsequent implementation of a plan for improvement.", "measureId": "IA_BMH_12", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "G0057", "M0001", "M1370" ] }, { "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", "pcf", "app1", "M0001", "M0003", "M0004", "M1367", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367" ] }, { "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", "pcf", "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Implementation of a Personal Protective Equipment (PPE) Plan", "description": "Implement a plan to acquire, store, maintain, and replenish supplies of personal protective equipment (PPE) for all clinicians or other staff who are in physical proximity to patients.In accordance with guidance from the Centers for Disease Control and Prevention (CDC) the PPE plan should address:•\tConventional capacity: PPE controls that should be implemented in general infection prevention and control plans in healthcare settings, including training in proper PPE use.•\tContingency capacity: actions that may be used temporarily during periods of expected PPE shortages.•\tCrisis capacity: strategies that may need to be considered during periods of known PPE shortages.The PPE plan should address all of the following types of PPE:•\tStandard precautions (e.g., hand hygiene, prevention of needle-stick or sharps injuries, safe waste management, cleaning and disinfection of the environment)•\tEye protection•\tGowns (including coveralls or aprons)•\tGloves•\tFacemasks•\tRespirators (including N95 respirators)", "measureId": "IA_ERP_4", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "emergencyResponseAndPreparedness", "allowedPrograms": [ "mips", "pcf", "app1", "M0001" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0055", "M0001", "M1368" ] }, { "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", "pcf", "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "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", "pcf", "app1", "M0001", "M0003", "M0004" ] }, { "category": "ia", "title": "Participation in Joint Commission Evaluation Initiative", "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.", "measureId": "IA_PSPA_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "M0001" ] }, { "category": "ia", "title": "Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.", "description": "Use decision support - ideally platform-agnostic, interoperable clinician decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs. Clinicians should focus on utilizing open-source, freely available, interoperable CDS in completing the requirements of this activity.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "G0059", "M0001", "M0002", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001" ] } ], "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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0002", "clinicalTopic": "Kidney Disease", "title": "Optimal Care for Kidney Health", "description": "The Optimal Care for Kidney Health MVP focuses on the clinical theme of providing fundamental treatment and management of costly clinical conditions that contribute to, or may result from, kidney disease.", "specialtiesMostApplicableTo": [ "Nephrology" ], "clinicalTopics": "Kidney Disease", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", "eMeasureId": "CMS122v12", "nqfEMeasureId": null, "nqfId": "0059", "measureId": "001", "description": "Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.", "measureType": "intermediateOutcome", "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": "singlePerformanceRate", "companionMeasureId": [ "001SSP" ], "allowedPrograms": [ "mips", "pcf", "app1", "M0002", "M0005" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_001_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_001_MIPSCQM.pdf", 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"rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "title": "Kidney Health Evaluation", "eMeasureId": "CMS951v2", "nqfEMeasureId": null, "nqfId": null, "measureId": "488", "description": "Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.", "measureType": "process", "isHighPriority": false, "primarySteward": "National Kidney Foundation", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": true, "isIcdImpacted": false, "clinicalGuidelineChanged": [ "electronicHealthRecord" ], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0002" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "preventiveMedicine", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_488_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0951v2" }, "eMeasureUuid": "2c928082-84ce-8286-0185-30f50cd0190f", "strata": [ { "description": "Patients who received a kidney health evaluation defined by an eGFR AND uACR within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "8949FAFC-6ADB-4499-AAC0-FD415D8167FC", "denominatorUuid": "14CF30C1-086C-4128-81AD-85D19BBEA671", "numeratorUuid": "36C34866-1126-4C38-827B-AA3FA4D34976", "denominatorExclusionUuid": "D4E27C5C-032A-448F-877C-71A1C44D478F" } } ] }, { "title": "Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1662", "measureId": "489", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.", "measureType": "process", "isHighPriority": false, "primarySteward": "Renal Physicians Association", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "geriatrics", "nephrology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_489_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0005", "M1366", "M1368" ], "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/2024_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 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" } ] }, { "title": "Gains in Patient Activation Measure (PAM) Scores at 12 Months", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "503", "description": "The Patient Activation Measure (PAM) (Registered Trademark) is a 10- or 13- item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM performance measure (PAM-PM) is the change in score on the PAM from baseline to follow-up measurement.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0055", "M0001", "M0002", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_503_MIPSCQM_Spec_and_Addendum.zip" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period." }, { "name": "6points", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month 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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "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", "pcf", "app1", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M1366", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0054", "G0057", "G0059", "M0002", "M0005" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M0005", "M1368" ] }, { "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", "pcf", "app1", "G0054", "G0055", "M0002", "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "category": "ia", "title": "Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.", "description": "Use decision support - ideally platform-agnostic, interoperable clinician decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs. Clinicians should focus on utilizing open-source, freely available, interoperable CDS in completing the requirements of this activity.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "G0059", "M0001", "M0002", "M1370" ] } ], "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/2023-12-05-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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "M0001", "M0002", "M0003", "M0004", "M0005" ], "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/2024_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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": "CMS68v13", "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 Services", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0003", "M1368" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_130_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0068v13" }, "eMeasureUuid": "2c928082-86db-6718-0187-0b4977140ad5", "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": "018818BA-BAEE-4F63-B345-0ECF647B7580", "denominatorUuid": "F0F5F489-3AE0-4128-A3D3-7427B5F333A4", "numeratorUuid": "A65C0BE1-19D2-40E5-910D-9B95960C4B6C", "denominatorExceptionUuid": "294E02A5-FBA5-4863-B215-D25B396C3E79" } } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_419_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "title": "Gains in Patient Activation Measure (PAM) Scores at 12 Months", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "503", "description": "The Patient Activation Measure (PAM) (Registered Trademark) is a 10- or 13- item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM performance measure (PAM-PM) is the change in score on the PAM from baseline to follow-up measurement.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0055", "M0001", "M0002", "M0003" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_503_MIPSCQM_Spec_and_Addendum.zip" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "overall", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period." }, { "name": "6points", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month 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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M1366", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "M0001", "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "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", "pcf", "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", "pcf", "app1", "M0001", "M0003", "M0004", "M1367", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M0005", "M1368" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "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", "pcf", "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", "pcf", "app1", "M0003", "M0004", "M1370" ] } ], "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "M0001", "M0002", "M0003", "M0004", "M0005" ], "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/2024_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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": "CMS156v12", "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", "companionMeasureId": [], "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/2024_Measure_238_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0156v12" }, "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": "1D3F49A0-F7A0-4E55-B953-DB944A082814", "denominatorUuid": "4960C71F-4317-4A3A-85FF-A0144EEFCBE5", "numeratorUuid": "6CC7B742-D134-49C1-95B9-35CA2E96D754", "denominatorExclusionUuid": "DA1FD97B-4CD9-4BFD-9DEA-60146DCACF2D" }, "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": "07BFBC59-A849-4BA4-8998-9C7876573D4E", "denominatorUuid": "D17677FA-08EB-4729-B22D-33874A21216F", "numeratorUuid": "3ED7845E-19B0-476B-9650-D439EB4E5900", "denominatorExclusionUuid": "8EF5897B-E8CD-46AB-B5E3-5E543E3A47FC" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "3233FCCF-FA30-41B3-8A3D-13B0E3F2FC97", "denominatorUuid": "4323442F-0C78-4BE2-B2D8-982A5BD89A4F", "numeratorUuid": "6300B4BC-C38E-41D4-A904-1D9D76964F98", "denominatorExclusionUuid": "BAB26534-B8DA-415B-8AC6-7C87CC4BCDA9" }, "name": "totalRate" } ], "eMeasureUuid": "2c928084-82ea-d7c5-0183-6293dcff1e19" }, { "title": "Dementia: Cognitive Assessment", "eMeasureId": "CMS149v12", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0149v12" }, "eMeasureUuid": "2c928082-86db-6718-0186-ec153eff0520", "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": "673EA403-B47A-4D1B-AC0E-21433ECB2F6F", "denominatorUuid": "0560F410-479D-4AAC-8637-C60A33BD9EBA", "numeratorUuid": "A0400F83-1D8C-4EAE-8477-970F25C28916", "denominatorExceptionUuid": "ECB48742-57C1-44DA-9EAF-14FC0BC55F9B" } } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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", "companionMeasureId": [], "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/2024_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", "companionMeasureId": [], "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/2024_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": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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, lawful physician-hastened death, or hospice) or whose existing end of life plan was reviewed or updated at least once annually or more frequency as clinically indicated (i.e., rapid progression)", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_386_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M1366", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "M0001", "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "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", "pcf", "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", "pcf", "app1", "M0001", "M0003", "M0004", "M1367", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M0005", "M1368" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "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", "pcf", "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", "pcf", "app1", "M0003", "M0004", "M1370" ] } ], "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0005", "clinicalTopic": "Preventive Care", "title": "Value in Primary Care", "description": "The Value in Primary Care 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": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", "eMeasureId": "CMS122v12", "nqfEMeasureId": null, "nqfId": "0059", "measureId": "001", "description": "Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.", "measureType": "intermediateOutcome", "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": "singlePerformanceRate", "companionMeasureId": [ "001SSP" ], "allowedPrograms": [ "mips", "pcf", "app1", "M0002", "M0005" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_001_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_001_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0122v12" }, "eMeasureUuid": "2c928084-83d3-1b44-0183-eb75dc8a03db", "strata": [ { "description": "Patients whose most recent HbA1c level (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "F09F8D18-F787-46EA-8791-3D3EF50A4C72", "denominatorUuid": "66505C6C-AAB0-4232-B0CA-15FB438090F4", "numeratorUuid": "95BCB9D4-86A8-43C1-BE29-7440A2ECE294", "denominatorExclusionUuid": "6AD9B271-BBB4-4BB6-95B1-D1A7E50D812F" } } ], "eligibilityOptions": [ { "diagnosisCodes": [ "E10.10", "E10.11", "E10.21", "E10.22", "E10.29", "E10.311", "E10.319", "E10.3211", "E10.3212", "E10.3213", "E10.3219", "E10.3291", "E10.3292", "E10.3293", "E10.3299", "E10.3311", "E10.3312", "E10.3313", "E10.3319", "E10.3391", "E10.3392", "E10.3393", "E10.3399", "E10.3411", "E10.3412", "E10.3413", "E10.3419", "E10.3491", "E10.3492", "E10.3493", "E10.3499", "E10.3511", "E10.3512", "E10.3513", "E10.3519", "E10.3521", "E10.3522", "E10.3523", "E10.3529", "E10.3531", "E10.3532", "E10.3533", "E10.3539", "E10.3541", "E10.3542", "E10.3543", "E10.3549", "E10.3551", "E10.3552", "E10.3553", "E10.3559", "E10.3591", "E10.3592", "E10.3593", "E10.3599", "E10.36", "E10.37X1", "E10.37X2", "E10.37X3", "E10.37X9", "E10.39", "E10.40", "E10.41", "E10.42", "E10.43", "E10.44", "E10.49", "E10.51", "E10.52", "E10.59", "E10.610", "E10.618", "E10.620", "E10.621", "E10.622", "E10.628", "E10.630", "E10.638", "E10.641", "E10.649", "E10.65", "E10.69", "E10.8", "E10.9", "E11.00", "E11.01", "E11.21", "E11.22", "E11.29", "E11.311", "E11.319", "E11.3211", "E11.3212", "E11.3213", "E11.3219", "E11.3291", "E11.3292", "E11.3293", "E11.3299", "E11.3311", "E11.3312", "E11.3313", "E11.3319", "E11.3391", "E11.3392", "E11.3393", "E11.3399", "E11.3411", "E11.3412", "E11.3413", "E11.3419", "E11.3491", "E11.3492", "E11.3493", "E11.3499", "E11.3511", "E11.3512", "E11.3513", "E11.3519", "E11.3521", "E11.3522", "E11.3523", "E11.3529", "E11.3531", "E11.3532", "E11.3533", "E11.3539", "E11.3541", "E11.3542", "E11.3543", "E11.3549", "E11.3551", "E11.3552", "E11.3553", "E11.3559", "E11.3591", "E11.3592", "E11.3593", "E11.3599", "E11.36", "E11.37X1", "E11.37X2", "E11.37X3", "E11.37X9", "E11.39", "E11.40", "E11.41", "E11.42", "E11.43", "E11.44", "E11.49", "E11.51", "E11.52", "E11.59", "E11.610", "E11.618", "E11.620", "E11.621", "E11.622", "E11.628", "E11.630", "E11.638", "E11.641", "E11.649", "E11.65", "E11.69", "E11.8", "E11.9", "E13.00", "E13.01", "E13.10", "E13.11", "E13.21", "E13.22", "E13.29", "E13.311", "E13.319", "E13.3211", "E13.3212", "E13.3213", "E13.3219", "E13.3291", "E13.3292", "E13.3293", "E13.3299", "E13.3311", "E13.3312", "E13.3313", "E13.3319", "E13.3391", "E13.3392", "E13.3393", "E13.3399", "E13.3411", "E13.3412", "E13.3413", "E13.3419", "E13.3491", "E13.3492", "E13.3493", "E13.3499", "E13.3511", "E13.3512", "E13.3513", "E13.3519", "E13.3521", "E13.3522", "E13.3523", "E13.3529", "E13.3531", "E13.3532", "E13.3533", "E13.3539", "E13.3541", "E13.3542", "E13.3543", "E13.3549", "E13.3551", "E13.3552", "E13.3553", "E13.3559", "E13.3591", "E13.3592", "E13.3593", "E13.3599", "E13.36", "E13.37X1", "E13.37X2", "E13.37X3", "E13.37X9", "E13.39", "E13.40", "E13.41", "E13.42", "E13.43", "E13.44", "E13.49", "E13.51", "E13.52", "E13.59", "E13.610", "E13.618", "E13.620", "E13.621", "E13.622", "E13.628", "E13.630", "E13.638", "E13.641", "E13.649", "E13.65", "E13.69", "E13.8", "E13.9", "O24.011", "O24.012", "O24.013", "O24.019", "O24.02", "O24.03", "O24.111", "O24.112", "O24.113", "O24.119", "O24.12", "O24.13", "O24.311", "O24.312", "O24.313", "O24.319", "O24.32", "O24.33", "O24.811", "O24.812", "O24.813", "O24.819", "O24.82", "O24.83" ], "maxAge": 75, "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "97802" }, { "code": "97803" }, { "code": "97804" }, { "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": "G0270" }, { "code": "G0271" }, { "code": "G0438" }, { "code": "G0439" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2081" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2090" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2091" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9687" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9988" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "M1211" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "M1212" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3044F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3051F" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3052F" } ] } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "G0055", "M0001", "M0002", "M0003", "M0004", "M0005" ], "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/2024_Measure_047_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_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" ] }, 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"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": "Initiation and Engagement of Substance Use Disorder Treatment", "eMeasureId": "CMS137v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "305", "description": "Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported):\na. Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode. \nb. Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.", "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": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0137v12" }, "overallAlgorithm": "simpleAverage", "strata": [ { "description": "Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode.", "eMeasureUuids": { "initialPopulationUuid": "703CE63C-957D-4214-AAEF-6DE14AE91E80", "denominatorUuid": "CBB623A8-C906-4712-983B-A532F984C2E9", "numeratorUuid": "D2C1C13B-097B-4210-922F-7AAE70F50F46", "denominatorExclusionUuid": "A6BAB6F7-FEB7-465E-8669-B48C2A05A003", "strata": [ "404DA201-FD78-41DF-89F8-57E135602098", "C8C9D5C1-4D6D-4F11-BA18-09645919EE7E", "BB3F8E59-845E-4D0A-BEE2-30D270EAC5CD" ] }, "name": "14Days" }, { "description": "Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.", "eMeasureUuids": { "initialPopulationUuid": "6492A3E6-D8C8-40A1-B280-909DB3436D1E", "denominatorUuid": "1F384AE6-DC33-4464-A743-D883C75BDCE9", "numeratorUuid": "3C89FB2F-3335-4384-8F25-FB58A1B00AE3", "denominatorExclusionUuid": "353DB0FA-5117-40DD-A989-8FA220D184BC", "strata": [ "E96FDC2B-1E60-41FE-A93D-ED20407BFDB5", "54B42C7D-4F4D-4F6B-BCB8-920B974DFC9C", "6834216F-BB45-4BFE-B326-5D710D33E041" ] }, "name": "34Days" } ], "eMeasureUuid": "2c928084-82ea-d7c5-0182-ec98d1c20129" }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0057", "M0001", "M0005" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {} }, { "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "eMeasureId": "CMS347v7", "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 performance period:\r\n•\tAll patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR\r\n•\tPatients aged 20 to 75 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\r\n•\tPatients aged 40 to 75 years with a diagnosis of diabetes; OR\r\n•\tPatients aged 40 to 75 with a 10-year ASCVD risk score of ≥ 20 percent.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0054", "M0005" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_438_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0347v7" }, "historic_benchmarks": { "registry": "removed", "electronicHealthRecord": "removed" }, "eMeasureUuid": "2c928082-82cb-a3f5-0182-cc688be40080", "strata": [ { "description": "All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure", "eMeasureUuids": { "initialPopulationUuid": "0B4F91D7-B2F9-48AF-A3ED-9115908DCAFE", "denominatorUuid": "34D89E97-4B99-43BB-97C7-C071F0DF971A", "numeratorUuid": "D7F7EDC4-8930-4656-96C5-818874EDA005", "denominatorExceptionUuid": "01D44136-D906-4907-95C4-08D6CE12621E", "denominatorExclusionUuid": "26B642A2-FA54-4CDD-9777-340A16FCB119" } }, { "description": "Patients aged 20 to 75 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": "45432B7C-8E52-42C9-9901-EBC06AA312EA", "denominatorUuid": "6498FD8C-CC34-4A75-97BB-479ED9C7E7B2", "numeratorUuid": "3768636A-6914-4E99-A1FF-86985EA906CE", "denominatorExceptionUuid": "295A9E4F-F784-4DE5-B228-8094E589B6EB", "denominatorExclusionUuid": "0C5DCCA9-17F2-41FC-9898-2E69F6BD4D52" } }, { "description": "Patients aged 40-75 years with a diagnosis of diabetes", "eMeasureUuids": { "initialPopulationUuid": "A1AB27A9-7C38-44A6-9FD5-4CCAD4015D2F", "denominatorUuid": "B84D1E69-BE12-429B-94BB-C52A6C7C05D1", "numeratorUuid": "AA438B03-6489-404B-B9E1-519A3CBBA075", "denominatorExceptionUuid": "A07A4226-5C2F-46CE-AE94-4DC932D1FC2E", "denominatorExclusionUuid": "DC9CE27C-94EF-4D4D-B2B9-20BB47ECB959" } }, { "description": "Patients aged 40 to 75 with a 10-year ASCVD risk score of >= 20 percent", "eMeasureUuids": { "initialPopulationUuid": "8B574B6B-8D8A-4E82-B1D5-193593C79E03", "denominatorUuid": "DCD01DD8-1B0B-4BDA-A69C-F928346A6B51", "numeratorUuid": "327F02A6-9AB0-4B06-8CD9-EB8805A6E344", "denominatorExceptionUuid": "BD48F0E9-0218-4381-94E1-6A12DF7BDF68", "denominatorExclusionUuid": "B0A97297-2AF3-414F-80A8-8DBA5D14A604" } } ] }, { "title": "HIV Screening", "eMeasureId": "CMS349v6", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0349v6" }, "eMeasureUuid": "2c928082-86db-6718-0187-0a05d6d40a25", "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "67CF99E8-D390-44E4-A844-A1156D58DAF7", "denominatorUuid": "BB5D4991-83D5-4071-8F96-EE7FE11968F1", "numeratorUuid": "1E6C29F5-22B3-45CC-B11E-7DF0B25E86C1", "denominatorExceptionUuid": "4133AB59-F9DC-4C0F-A697-C2AB4C160769", "denominatorExclusionUuid": "FA1DD323-C493-46B2-9A7B-C4109109FC7A" } } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_483_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0005", "M1366", "M1368" ], "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/2024_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 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" } ] }, { "title": "Preventive Care and Wellness (composite)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "497", "description": "Percentage of patients who received age- and sex-appropriate preventive screenings and wellness services. This measure is a composite of seven component measures that are based on recommendations for preventive care by the U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), American Association of Clinical Endocrinology (AACE), and American College of Endocrinology (ACE).", "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_497_MIPSCQM_Spec_and_Addendum.zip" }, "overallAlgorithm": "weightedAverage", "strata": [ { "name": "influenza", "description": "Percentage of patients who received an influenza immunization or who reported previous receipt of an influenza immunization" }, { "name": "pneumococcal", "description": "Percentage of patients who received a pneumococcal vaccination on or after their 60th birthday" }, { "name": "mammogram", "description": "Percentage of patients with a mammogram during the 27 months prior to the end of the measurement period" }, { "name": "colorectal", "description": "Percentage of patients with one or more appropriate colorectal cancer screenings" }, { "name": "BMI", "description": "Percentage of patients with a documented BMI, with follow-up plan if applicable, during the encounter or during the previous 12 months" }, { "name": "tobacco", "description": "Percentage of patients screened for tobacco use and, if identified as a tobacco user, received cessation intervention during the encounter or within the previous six months" }, { "name": "HBP", "description": "Percentage of visits where patients were screened for high blood pressure with a documented follow-up plan, as indicated" } ] }, { "title": "Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "504", "description": "Percentage of adult aged 18 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_504_MIPSCQM.pdf" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "24hour", "description": "Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter)" }, { "name": "overall", "description": "Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation." } ] } ], "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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M0005", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0054", "G0057", "G0059", "M0002", "M0005" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M0005", "M1368" ] }, { "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", "pcf", "app1", "G0054", "G0055", "M0002", "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "category": "ia", "title": "Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services", "description": "Establish policies and procedures to improve practice capacity to increase HIV prevention screening, improve HIV prevention education and awareness, and reduce disparities in pre-exposure prophylaxis (PrEP) uptake. Use one or more of the following activities:\n• Implement electronic health record (EHR) prompts or clinical decision support tools to increase appropriate HIV prevention screening; \n• Require that providers and designated clinical staff take part in at least one educational opportunity that includes components on the importance and application of HIV prevention screening and PrEP initiation in clinical practice; and/or \n• Assess and refine current policies for HIV prevention screening, including integrated sexually transmitted infection (STI)/HIV testing processes, universal HIV screening, and PrEP initiation.", "measureId": "IA_PM_22", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M0005", "M1368" ] }, { "category": "ia", "title": "Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines", "description": "Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool within the electronic health record (EHR) system to provide clinicians with ready access to and assisted interpretation of the most up-to-date clinical practice guidelines in CCSM to ensure adequate screening, timely follow-up, and optimal patient care.\n\nThe CCSM CDS helps ensure that patient populations receive adequate screening and management, according to evidence-based recommendations in the United States Preventive Services Task Force (USPSTF) screening and American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for cervical cancer. The CDS integrates into the clinical workflow a clinician-facing dashboard to support the clinician’s awareness and adoption of and preventive care for cervical cancer, including screening and any necessary follow-up treatment.\n\nThe CCSM CDS is fully conformant with the HL7 Fast Healthcare Interoperability Resources (FHIR) standard, so it can be used with any certified EHR platform. The CDS Hooks and SMART-on-FHIR interoperability interface standards provide two ways to integrate with the clinical workflow in a way that complements existing displays and information pre-visit, during visit, and for post-visit follow-up. CCSM CDS helps the clinician evaluate the patient’s clinical data against existing guidance and displays patient-specific recommendations.", "measureId": "IA_PM_23", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M0005", "M1366" ] } ], "costMeasures": [ { "category": "cost", "title": "Asthma/Chronic Obstructive Pulmonary Disease (COPD)", "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, the term \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure. The Asthma/COPD episode-based cost measure evaluates a clinician's or clinician group's risk-adjusted cost to Medicare for patients receiving medical care to manage and treat asthma or COPD. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician's role in managing care during an Asthma/COPD episode.", "measureId": "COST_ACOPD_1", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-chron-copd.pdf" }, "allowedPrograms": [ "mips", "app1", "M0005" ] }, { "category": "cost", "title": "Diabetes", "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, the term \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure. The Diabetes episode-based cost measure evaluates a clinician's or clinician group's risk-adjusted cost to Medicare for patients receiving medical care to manage and treat diabetes. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician's role in managing care during a Diabetes episode.", "measureId": "COST_D_1", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": null, "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-diabetes.pdf" }, "allowedPrograms": [ "mips", "app1", "M0005" ] }, { "category": "cost", "title": "Depression", "description": "Patients receiving medical care to manage and treat depression. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Depression episode.", "measureId": "COST_DEP_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "M0005", "M1369" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-depression-v2.pdf" } }, { "category": "cost", "title": "Heart Failure", "description": "Patients receiving medical care to manage and treat heart failure. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Heart Failure episode.", "measureId": "COST_HF_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "G0055", "M0005" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-heart-fail-v2.pdf" } }, { "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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1366", "clinicalTopic": "Women's Health", "title": "Focusing on Women’s Health", "description": "Focusing on Women’s Health MVP focuses on the clinical theme of providing treatment and management of women’s health.", "specialtiesMostApplicableTo": [ "Gynecology", "Obstetrics", "Urogynecology", "Nonphysician Practitioners", "Certified Nurse Mid-Wives", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Women's Health", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "048", "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_048_MIPSCQM.pdf" } }, { "title": "Breast Cancer Screening", "eMeasureId": "CMS125v12", "nqfEMeasureId": null, 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"denominatorUuid": "C74AE380-0593-4D95-BFD6-D71D3AF4AC8D", "numeratorUuid": "8113EBC1-FE78-4EEF-BD38-5A7EF93EF90F", "denominatorExclusionUuid": "C5EEC624-E6B5-4197-BF65-A932BC9D7CEA", "strata": [ "E85ECBA1-7955-4EB8-B520-70A2F3B78986", "47C21B1E-D2B7-4348-847E-9B055959943E" ] } } ] }, { "title": "Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "335", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_335_MIPSCQM.pdf" } }, { "title": "Maternity Care: Postpartum Follow-up and Care Coordination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "336", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_336_MIPSCQM.pdf" } }, { "title": "One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "400", "description": "Percentage of patients age >= 18 years have never been tested for Hepatitis C Virus (HCV) infection who receive an HCV infection test AND who have treatment initiated within three months or who are referred to a clinician who treats HCV infection within one month if tested positive for HCV.", "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": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_400_MIPSCQM.pdf" }, "overallAlgorithm": "simpleAverage", "historic_benchmarks": { "registry": "removed" }, "strata": [ { "name": "screening", "description": "Percentage of patients age >= 18 years who have never been tested for HCV antibodies and who receive an HCV antibody test." }, { "name": "follow-up/trtmt", "description": "Percentage of patients age >= 18 years who have a reactive HCV antibody test, who have a follow up HCV viral test, and if HCV viremia is detected, have treatment initiated within three months or are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test." } ] }, { "title": "Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2063", "measureId": "422", "description": "Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Urogynecologic Society", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_422_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_422_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "N81.10", "N81.11", "N81.12", "N81.2", "N81.3", "N81.4", "N81.89", "N81.9" ], "minAge": 0, "optionGroup": "00", "procedureCodes": [ { "code": "58150", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58152", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58180", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58260", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58262", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58263", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58267", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58270", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58275", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58280", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58290", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58291", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58292", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58294", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58541", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58542", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58543", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58544", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58550", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58552", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58553", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58554", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58570", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58571", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58572", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] }, { "code": "58573", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02", "10" ] } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9607" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9606" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9608" } ] } ] }, { "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "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/2024_Measure_431_MIPSCQM.pdf" }, "overallAlgorithm": "split", "strata": [ { "name": "reporting", "description": "Patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method" }, { "name": "performance", "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": "Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "432", "description": "Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urogynecologic Society", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology", "urology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_432_MIPSCQM.pdf" } }, { "title": "Appropriate Workup Prior to Endometrial Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "448", "description": "Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_448_MIPSCQM.pdf" } }, { "title": "Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture", "eMeasureId": "CMS249v6", "nqfEMeasureId": "3475e", "nqfId": null, "measureId": "472", "description": "Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0249v6" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-204c9a0c1112", "strata": [ { "description": "Female patients who received an order for at least one DXA scan in the measurement period", "eMeasureUuids": { "initialPopulationUuid": "CBBBA0E8-63BC-4E0F-BFA4-A28A95C1527D", "denominatorUuid": "EEEAFBC3-AAFB-417C-81BD-9034CFE7F5E1", "numeratorUuid": "769B6087-B19F-4FE1-88C8-C4519D1A6674", "denominatorExclusionUuid": "F5F72298-D99A-4669-A1C1-F6851CCE3303", "numeratorExclusionUuid": "06BE45AA-51B5-4E8E-BDBF-4C0E68E7B5CC" } } ] }, { "title": "HIV Screening", "eMeasureId": "CMS349v6", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0349v6" }, "eMeasureUuid": "2c928082-86db-6718-0187-0a05d6d40a25", "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "67CF99E8-D390-44E4-A844-A1156D58DAF7", "denominatorUuid": "BB5D4991-83D5-4071-8F96-EE7FE11968F1", "numeratorUuid": "1E6C29F5-22B3-45CC-B11E-7DF0B25E86C1", "denominatorExceptionUuid": "4133AB59-F9DC-4C0F-A697-C2AB4C160769", "denominatorExclusionUuid": "FA1DD323-C493-46B2-9A7B-C4109109FC7A" } } ] }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0005", "M1366", "M1368" ], "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/2024_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 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" } ] }, { "title": "Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "496", "description": "Percentage of pregnant or postpartum patients who received a cardiovascular disease (CVD) risk assessment with a standardized instrument.", "measureType": "process", "isHighPriority": false, "primarySteward": "University of California, Irvine", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_496_MIPSCQM.pdf" } }, { "measureId": "UREQA8", "title": "Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved", "description": "Percentage of patients aged 65 years and older diagnosed with osteopenia or osteoporosis whose most recent serum 25 Hydroxy-Vitamin D results is greater than or equal to 30.0 ng/dL. \nReporting Frequency:\nThis measure is reported once per reporting period.", "nqfId": null, "measureType": "outcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "firstPerformanceYear": 2022, "allowedVendors": [ "1649514" ], "allowedPrograms": [ "mips", "pcf", "M1366" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Enhance Engagement of Medicaid and Other Underserved Populations", "description": "To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat data (i.e., data measuring the time between clinician identifying a need for an appointment and the patient having a scheduled appointment) to identify patterns by which care or engagement with Medicaid patients or other groups of underserved patients has not achieved standard practice guidelines; and with this information, create, implement, and monitor an approach for improvement. This approach may include screening for patient barriers to treatment, especially transportation barriers, and providing resources to improve engagement (e.g., state Medicaid non-emergency medical transportation benefit).", "measureId": "IA_AHE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1368", "M1369" ] }, { "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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M1366", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "category": "ia", "title": "Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice", "description": "Create and implement a plan for trauma-informed care (TIC) that recognizes the potential impact of trauma experiences on patients and takes steps to mitigate the effects of adverse events in order to avoid re-traumatizing or triggering past trauma. Actions in this plan may include, but are not limited to, the following:•\tIncorporate trauma-informed training into new employee orientation •\tOffer annual refreshers and/or trainings for all staff •\tRecommend and supply TIC materials to third party partners, including care management companies and billing services•\tIdentify patients using a screening methodology•\tFlag charts for patients with one or more adverse events that might have caused trauma•\tUse ICD-10 diagnosis codes for adverse events when appropriateTIC is a strengths-based healthcare delivery approach that emphasizes physical, psychological, and emotional safety for both trauma survivors and their providers. Core components of a TIC approach are: awareness of the prevalence of trauma; understanding of the impact of past trauma on services utilization and engagement; and a commitment and plan to incorporate that understanding into training, policy, procedure, and practice.", "measureId": "IA_BMH_11", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "M1366" ] }, { "category": "ia", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women", "description": "Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.", "measureId": "IA_BMH_14", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1369" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M1366" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "category": "ia", "title": "Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines", "description": "Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool within the electronic health record (EHR) system to provide clinicians with ready access to and assisted interpretation of the most up-to-date clinical practice guidelines in CCSM to ensure adequate screening, timely follow-up, and optimal patient care.\n\nThe CCSM CDS helps ensure that patient populations receive adequate screening and management, according to evidence-based recommendations in the United States Preventive Services Task Force (USPSTF) screening and American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for cervical cancer. The CDS integrates into the clinical workflow a clinician-facing dashboard to support the clinician’s awareness and adoption of and preventive care for cervical cancer, including screening and any necessary follow-up treatment.\n\nThe CCSM CDS is fully conformant with the HL7 Fast Healthcare Interoperability Resources (FHIR) standard, so it can be used with any certified EHR platform. The CDS Hooks and SMART-on-FHIR interoperability interface standards provide two ways to integrate with the clinical workflow in a way that complements existing displays and information pre-visit, during visit, and for post-visit follow-up. CCSM CDS helps the clinician evaluate the patient’s clinical data against existing guidance and displays patient-specific recommendations.", "measureId": "IA_PM_23", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M0005", "M1366" ] }, { "category": "ia", "title": "Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)", "description": "Address inequities in health outcomes by using population health data analysis tools to identify health inequities in the community and practice and assess options for effective and relevant interventions such as Population Health Toolkit or other resources identified by the clinician, practice, or by CMS. Based on this information, create, refine, and implement an action plan to address and close inequities in health outcomes and/or health care access, quality, and safety.", "measureId": "IA_PM_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1368", "M1369" ] } ], "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] }, { "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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1367", "clinicalTopic": "Otolaryngology", "title": "Quality Care for the Treatment of Ear, Nose, and Throat Disorders", "description": "The Quality Care for the Treatment of Ear, Nose, and Throat Disorders MVP focuses on the clinical theme of providing care for patients experiencing some of the most common otolaryngology conditions such as, but not limited to: otologic conditions, chronic rhinosinusitis (CRS), age-related hearing loss (ARHL) and otitis media.", "specialtiesMostApplicableTo": [ "Otolaryngology" ], "clinicalTopics": "Otolaryngology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "eMeasureId": "CMS69v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "128", 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Research could include addressing health-related social needs like food insecurity, housing insecurity, transportation barriers, utility needs, and interpersonal safety.", "measureId": "IA_AHE_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1367", "M1368", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "M0001", "M0003", "M0004", "M1367", "M1370" ] }, { "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", "pcf", "app1", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0002", "M0003", "M0004", "M0005", "M1367" ] }, { "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", "pcf", "app1", "G0055", "G0057", "G0058", "G0059", "M1367" ] } ], "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1368", "clinicalTopic": "Infectious Disease, Immunology", "title": "Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV", "description": "The Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV MVP focuses on the clinical theme of promoting quality care for patients suffering from infectious disorders.", "specialtiesMostApplicableTo": [ "Infectious Disease", "Immunology" ], "clinicalTopics": "Infectious Disease, Immunology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Appropriate Treatment for Upper Respiratory Infection (URI)", "eMeasureId": "CMS154v12", "nqfEMeasureId": null, "nqfId": "0069", "measureId": "065", "description": "Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0057", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "infectiousDisease", "pediatrics", "urgentCare" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_065_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0154v12" }, "eMeasureUuid": "2c928084-8389-524e-0183-c8d7a6700f02", "strata": [ { "description": "URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection", "eMeasureUuids": { "initialPopulationUuid": "83DB196F-463B-4E77-ABC4-7B38F0C60D36", "denominatorUuid": "766AC88F-A02D-42E1-B34C-7BFB2874A824", "numeratorUuid": "EE960FF9-ED6B-49E8-A1CC-D0C93513355B", "denominatorExclusionUuid": "8DABD0C9-3DE6-4221-9F84-0E2EB872075F", "strata": [ "79520F15-07EF-4D9C-BA96-080F356FF328", "B5624EA1-BB69-4366-B65F-2192D2BB7BA7", "C4096D01-6428-4021-8E72-AE255C8874BE" ] } } ] }, { "title": "Documentation of Current Medications in the Medical Record", "eMeasureId": "CMS68v13", "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 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"clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "emergencyMedicine", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_134_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_134_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0002v13" }, "eMeasureUuid": "2c928083-8651-08a3-0186-c82995a91d28", "strata": [ { "description": "Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "AD83208C-1313-401E-BB62-ABCCE0982B49", "denominatorUuid": "696066C7-C558-4849-A325-A3CDDB58CF8F", "numeratorUuid": "E2557B71-1B97-413F-BE26-2B037E4D590B", "denominatorExceptionUuid": "FBA7B9D9-8588-4CB2-AB72-642CBD980334", "denominatorExclusionUuid": "E52F7FAE-96D9-417A-8538-6E3DB4A31D7A" } } ], "eligibilityOptions": [ { "diagnosisExclusionCodes": [ "F30.10", "F30.11", "F30.12", "F30.13", "F30.2", "F30.3", "F30.4", "F30.8", "F30.9", "F31.0", "F31.10", "F31.11", "F31.12", "F31.13", "F31.2", "F31.30", "F31.31", "F31.32", "F31.4", "F31.5", "F31.60", "F31.61", "F31.62", "F31.63", "F31.64", "F31.70", "F31.71", "F31.72", "F31.73", "F31.74", "F31.75", "F31.76", "F31.77", "F31.78", "F31.81", "F31.89", "F31.9" ], "minAge": 12, "optionGroup": "00", "procedureCodes": [ { "code": "59400" }, { "code": "59510" }, { "code": "59610" }, { "code": "59618" }, { "code": "90791" }, { "code": "90792" }, { "code": "90832" }, { "code": "90834" }, { "code": "90837" }, { "code": "92622" }, { "code": "92625" }, { "code": "96105" }, { "code": "96110" }, { "code": "96112" }, { "code": "96116" }, { "code": "96125" }, { "code": "96136" }, { "code": "96138" }, { "code": "96156" }, { "code": "96158" }, { "code": "97161" }, { "code": "97162" }, { "code": "97163" }, { "code": "97164" }, { "code": "97165" }, { "code": "97166" }, { "code": "97167" }, { "code": "97802" }, { "code": "97803" }, { "code": "98966" }, { "code": "98967" }, { "code": "98968" }, { "code": "99078" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307" }, { "code": "99308" }, { "code": "99309" }, { "code": "99310" }, { "code": "99315" }, { "code": "99316" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99384" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99394" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "99401" }, { "code": "99402" }, { "code": "99403" }, { "code": "99424" }, { "code": "99441" }, { "code": "99442" }, { "code": "99443" }, { "code": "99483" }, { "code": "99484" }, { "code": "99491" }, { "code": "99492" }, { "code": "99493" }, { "code": "G0101" }, { "code": "G0270" }, { "code": "G0271" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" }, { "code": "G0444" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8433" } ] }, { "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": "Sexually Transmitted Infection (STI) Testing for People with HIV", "eMeasureId": "CMS1188v1", "nqfEMeasureId": null, "nqfId": null, "measureId": "205", "description": "Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the performance period.", "measureType": "process", "isHighPriority": false, "primarySteward": "Health Resources and Services Administration", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "infectiousDisease", "pediatrics" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_205_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms1188v1" }, "eMeasureUuid": "2c928082-86db-6718-0186-e6f01b5c037f", "strata": [ { "description": "Patients who were tested for each of the following at least once during the measurement period: syphilis, gonorrhea, and chlamydia", "eMeasureUuids": { "initialPopulationUuid": "324CDEA8-BCC3-4FCF-9C50-F761C0472647", "denominatorUuid": "F5D38923-28DF-4D69-8AEF-D815FEDD5D42", "numeratorUuid": "0A3BBBBD-6151-4113-96F5-4E8F194D19AF" } } ] }, { "title": "Childhood Immunization Status", "eMeasureId": "CMS117v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "240", "description": "Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "infectiousDisease", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0117v12" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-138ff3280ad1", "strata": [ { "description": "DTaP\nChildren with any of the following on or before the child’s second birthday meet criteria:\n- At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.\n- Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine.\n- Encephalitis due to the diphtheria, tetanus or pertussis vaccine.\n\nIPV\nChildren with either of the following on or before the child’s second birthday meet criteria:\n- At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.\n- Anaphylaxis due to the IPV vaccine.\n\nMMR\nChildren with any of the following meet criteria:\n- At least one MMR vaccination on or between the child’s first and second birthdays.\n- Anaphylaxis due to the MMR vaccine on or before the child’s second birthday.\n- All of the following anytime on or before the child’s second birthday (on the same or different date of service):\n - History of measles.\n - History of mumps.\n - History of rubella.\n\nHiB\nChildren with either of the following meet criteria on or before the child’s second birthday:\n- At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.\n- Anaphylaxis due to the HiB vaccine.\n\nHep B\nChildren with any of the following on or before the child’s second birthday meet criteria:\n- At least three hepatitis B vaccinations, with different dates of service.\n - One of the three vaccinations can be a newborn hepatitis B vaccination during the eight-day period that begins on the date of birth and ends seven days after the date of birth. For example, if the member’s date of birth is December 1, the newborn hepatitis B vaccination must be on or between December 1 and December 8.\n- Anaphylaxis due to the hepatitis B vaccine.\n- History of hepatitis B illness.\n\nVZV\nChildren with any of the following meet criteria:\n- At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays.\n- Anaphylaxis due to the VZV vaccine on or before the child’s second birthday.\n- History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.\n\nPCV\nChildren with either of the following on or before the child’s second birthday meet criteria:\n- At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.\n- Anaphylaxis due to the pneumococcal vaccine.\n\nHep A\nChildren with any of the following meet criteria:\n- At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays.\n- Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday.\n- History of hepatitis A illness on or before the child’s second birthday.\n\nRV\nChildren with any of the following meet criteria:\n- At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.\n- At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.\n- At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.\n- Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday.\n\nFlu\nChildren with either of the following on or before their second birthday meet criteria:\n- At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 6 months (180 days) after birth.\n - One of the two vaccinations can be a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday.\n- Anaphylaxis due to the influenza vaccine.", "eMeasureUuids": { "initialPopulationUuid": "1BF7CD8D-B257-401E-ABF7-252DABA0D209", "denominatorUuid": "74892E72-0D00-4391-8577-5C387410C89D", "numeratorUuid": "511390B8-515A-4CA0-B52D-68DBD9ABE83C", "denominatorExclusionUuid": "403C825E-43CA-410D-A105-62A9E7058BD0" } } ] }, { "title": "Chlamydia Screening for Women", "eMeasureId": "CMS153v12", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0153v12" }, "eMeasureUuid": "2c928084-82ea-d7c5-0183-6bf2f90320e6", "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "34EA6AAA-3940-444F-AF54-40F61808E3A7", "denominatorUuid": "C74AE380-0593-4D95-BFD6-D71D3AF4AC8D", "numeratorUuid": "8113EBC1-FE78-4EEF-BD38-5A7EF93EF90F", "denominatorExclusionUuid": "C5EEC624-E6B5-4197-BF65-A932BC9D7CEA", "strata": [ "E85ECBA1-7955-4EB8-B520-70A2F3B78986", "47C21B1E-D2B7-4348-847E-9B055959943E" ] } } ] }, { "title": "HIV Viral Suppression", "eMeasureId": "CMS314v1", "nqfEMeasureId": null, "nqfId": null, "measureId": "338", "description": "Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period, with an eligible encounter in the first 240 days of the performance period, whose last HIV viral load test result was less than 200 copies/mL during the performance period.", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_338_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0314v1" }, "eMeasureUuid": "2c928082-86db-6718-0187-03d1acee0811", "strata": [ { "description": "Patients with a last HIV viral load test result of less than 200 copies/mL during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "F8EEABA6-5F4A-435A-B0A5-25BB3D24205D", "denominatorUuid": "1633252F-B022-4E7D-8DDB-3D439A18AEE2", "numeratorUuid": "3723189C-3247-428F-AF1E-D2E510D0A9DB" } } ] }, { "title": "HIV Medical Visit Frequency", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "340", "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.", "measureType": "process", "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "infectiousDisease" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_340_MIPSCQM.pdf" } }, { "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "387", "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_387_MIPSCQM.pdf" } }, { "title": "One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "400", "description": "Percentage of patients age >= 18 years have never been tested for Hepatitis C Virus (HCV) infection who receive an HCV infection test AND who have treatment initiated within three months or who are referred to a clinician who treats HCV infection within one month if tested positive for HCV.", "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": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1366", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_400_MIPSCQM.pdf" }, "overallAlgorithm": "simpleAverage", "historic_benchmarks": { "registry": "removed" }, "strata": [ { "name": "screening", "description": "Percentage of patients age >= 18 years who have never been tested for HCV antibodies and who receive an HCV antibody test." }, { "name": "follow-up/trtmt", "description": "Percentage of patients age >= 18 years who have a reactive HCV antibody test, who have a follow up HCV viral test, and if HCV viremia is detected, have treatment initiated within three months or are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test." } ] }, { "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "401", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "internalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_401_MIPSCQM.pdf" } }, { "title": "HIV Screening", "eMeasureId": "CMS349v6", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0349v6" }, "eMeasureUuid": "2c928082-86db-6718-0187-0a05d6d40a25", "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "67CF99E8-D390-44E4-A844-A1156D58DAF7", "denominatorUuid": "BB5D4991-83D5-4071-8F96-EE7FE11968F1", "numeratorUuid": "1E6C29F5-22B3-45CC-B11E-7DF0B25E86C1", "denominatorExceptionUuid": "4133AB59-F9DC-4C0F-A697-C2AB4C160769", "denominatorExclusionUuid": "FA1DD323-C493-46B2-9A7B-C4109109FC7A" } } ] }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "M0002", "M0005", "M1366", "M1368" ], "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/2024_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 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": "Enhance Engagement of Medicaid and Other Underserved Populations", "description": "To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat data (i.e., data measuring the time between clinician identifying a need for an appointment and the patient having a scheduled appointment) to identify patterns by which care or engagement with Medicaid patients or other groups of underserved patients has not achieved standard practice guidelines; and with this information, create, implement, and monitor an approach for improvement. This approach may include screening for patient barriers to treatment, especially transportation barriers, and providing resources to improve engagement (e.g., state Medicaid non-emergency medical transportation benefit).", "measureId": "IA_AHE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1368", "M1369" ] }, { "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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "category": "ia", "title": "MIPS Eligible Clinician Leadership in Clinical Trials or CBPR", "description": "Lead clinical trials, research alliances, or community-based participatory research (CBPR) that identify tools, research, or processes that focus on minimizing disparities in healthcare access, care quality, affordability, or outcomes. Research could include addressing health-related social needs like food insecurity, housing insecurity, transportation barriers, utility needs, and interpersonal safety.", "measureId": "IA_AHE_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1367", "M1368", "M1369" ] }, { "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", "pcf", "app1", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0057", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M0005", "M1368" ] }, { "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", "pcf", "app1", "G0055", "M0001", "M1368" ] }, { "category": "ia", "title": "Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services", "description": "Establish policies and procedures to improve practice capacity to increase HIV prevention screening, improve HIV prevention education and awareness, and reduce disparities in pre-exposure prophylaxis (PrEP) uptake. Use one or more of the following activities:\n• Implement electronic health record (EHR) prompts or clinical decision support tools to increase appropriate HIV prevention screening; \n• Require that providers and designated clinical staff take part in at least one educational opportunity that includes components on the importance and application of HIV prevention screening and PrEP initiation in clinical practice; and/or \n• Assess and refine current policies for HIV prevention screening, including integrated sexually transmitted infection (STI)/HIV testing processes, universal HIV screening, and PrEP initiation.", "measureId": "IA_PM_22", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M0005", "M1368" ] }, { "category": "ia", "title": "Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)", "description": "Address inequities in health outcomes by using population health data analysis tools to identify health inequities in the community and practice and assess options for effective and relevant interventions such as Population Health Toolkit or other resources identified by the clinician, practice, or by CMS. Based on this information, create, refine, and implement an action plan to address and close inequities in health outcomes and/or health care access, quality, and safety.", "measureId": "IA_PM_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1368", "M1369" ] }, { "category": "ia", "title": "Completion of CDC Training on Antibiotic Stewardship", "description": "Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. 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_23", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "M1368" ] }, { "category": "ia", "title": "Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support", "description": "In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain via clinical decision support (CDS). For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.", "measureId": "IA_PSPA_32", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "M1368", "M1369" ] } ], "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/2023-12-13-mif-tpcc-v2.pdf" }, "allowedPrograms": [ "mips", "app1", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1369", "clinicalTopic": "Mental Health, Behavioral Health, Psychiatry", "title": "Quality Care in Mental Health and Substance Use Disorders", "description": "The Quality Care in Mental Health and Substance Use Disorders MVP focuses on the clinical theme of promoting prevention of and quality care in behavioral health, including mental health and substance use disorders (SUD).", "specialtiesMostApplicableTo": [ "Mental Health", "Behavioral Health", "Psychiatry" ], "clinicalTopics": "Mental Health, Behavioral Health, Psychiatry", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "title": "Anti-Depressant Medication Management", "eMeasureId": "CMS128v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "009", "description": "Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0128v12" }, "overallAlgorithm": "simpleAverage", "strata": [ { "description": "Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). ", "eMeasureUuids": { "initialPopulationUuid": "5C0C2E55-560F-42C1-85E0-2CE36D7F48B4", "denominatorUuid": "23702C38-4048-438D-BCFC-5B507AB0E058", "numeratorUuid": "D1230E54-3ED7-4E37-9BD9-14BD987A89CD", "denominatorExclusionUuid": "3810F33A-CC55-4949-9DE6-0CD5CCF31723" }, "name": "84Days" }, { "description": "Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "eMeasureUuids": { "initialPopulationUuid": "7FE1D093-EFE8-4A37-BB62-F54FE320ABD1", "denominatorUuid": "2C0FDE5F-C7A5-43A4-9AB2-EF1ED5AF9017", "numeratorUuid": "2707A6AA-72DE-4D68-B619-775D8715A7BE", "denominatorExclusionUuid": "C25C172D-A823-4ADD-AABD-4BF11ABA3928" }, "name": "180Days" } ], "eMeasureUuid": "2c928084-83d3-1b44-0183-ec9f5639051f" }, { "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "eMeasureId": "CMS2v13", "nqfEMeasureId": null, "nqfId": null, "measureId": "134", "description": "Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.", "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", "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "emergencyMedicine", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_134_MedicarePartBClaims.pdf", "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_134_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0002v13" }, "eMeasureUuid": "2c928083-8651-08a3-0186-c82995a91d28", "strata": [ { "description": "Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "AD83208C-1313-401E-BB62-ABCCE0982B49", "denominatorUuid": "696066C7-C558-4849-A325-A3CDDB58CF8F", "numeratorUuid": "E2557B71-1B97-413F-BE26-2B037E4D590B", "denominatorExceptionUuid": "FBA7B9D9-8588-4CB2-AB72-642CBD980334", "denominatorExclusionUuid": "E52F7FAE-96D9-417A-8538-6E3DB4A31D7A" } } ], "eligibilityOptions": [ { "diagnosisExclusionCodes": [ "F30.10", "F30.11", "F30.12", "F30.13", "F30.2", "F30.3", "F30.4", "F30.8", "F30.9", "F31.0", "F31.10", "F31.11", "F31.12", "F31.13", "F31.2", "F31.30", "F31.31", "F31.32", "F31.4", "F31.5", "F31.60", "F31.61", "F31.62", "F31.63", "F31.64", "F31.70", "F31.71", "F31.72", "F31.73", "F31.74", "F31.75", "F31.76", "F31.77", "F31.78", "F31.81", "F31.89", "F31.9" ], "minAge": 12, "optionGroup": "00", "procedureCodes": [ { "code": "59400" }, { "code": "59510" }, { "code": "59610" }, { "code": "59618" }, { "code": "90791" }, { "code": "90792" }, { "code": "90832" }, { "code": "90834" }, { "code": "90837" }, { "code": "92622" }, { "code": "92625" }, { "code": "96105" }, { "code": "96110" }, { "code": "96112" }, { "code": "96116" }, { "code": "96125" }, { "code": "96136" }, { "code": "96138" }, { "code": "96156" }, { "code": "96158" }, { "code": "97161" }, { "code": "97162" }, { "code": "97163" }, { "code": "97164" }, { "code": "97165" }, { "code": "97166" }, { "code": "97167" }, { "code": "97802" }, { "code": "97803" }, { "code": "98966" }, { "code": "98967" }, { "code": "98968" }, { "code": "99078" }, { "code": "99202" }, { "code": "99203" }, { "code": "99204" }, { "code": "99205" }, { "code": "99212" }, { "code": "99213" }, { "code": "99214" }, { "code": "99215" }, { "code": "99304" }, { "code": "99305" }, { "code": "99306" }, { "code": "99307" }, { "code": "99308" }, { "code": "99309" }, { "code": "99310" }, { "code": "99315" }, { "code": "99316" }, { "code": "99341" }, { "code": "99342" }, { "code": "99344" }, { "code": "99345" }, { "code": "99347" }, { "code": "99348" }, { "code": "99349" }, { "code": "99350" }, { "code": "99384" }, { "code": "99385" }, { "code": "99386" }, { "code": "99387" }, { "code": "99394" }, { "code": "99395" }, { "code": "99396" }, { "code": "99397" }, { "code": "99401" }, { "code": "99402" }, { "code": "99403" }, { "code": "99424" }, { "code": "99441" }, { "code": "99442" }, { "code": "99443" }, { "code": "99483" }, { "code": "99484" }, { "code": "99491" }, { "code": "99492" }, { "code": "99493" }, { "code": "G0101" }, { "code": "G0270" }, { "code": "G0271" }, { "code": "G0402" }, { "code": "G0438" }, { "code": "G0439" }, { "code": "G0444" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8433" } ] }, { "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": "Initiation and Engagement of Substance Use Disorder Treatment", "eMeasureId": "CMS137v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "305", "description": "Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported):\na. Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode. \nb. Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.", "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": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0137v12" }, "overallAlgorithm": "simpleAverage", "strata": [ { "description": "Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode.", "eMeasureUuids": { "initialPopulationUuid": "703CE63C-957D-4214-AAEF-6DE14AE91E80", "denominatorUuid": "CBB623A8-C906-4712-983B-A532F984C2E9", "numeratorUuid": "D2C1C13B-097B-4210-922F-7AAE70F50F46", "denominatorExclusionUuid": "A6BAB6F7-FEB7-465E-8669-B48C2A05A003", "strata": [ "404DA201-FD78-41DF-89F8-57E135602098", "C8C9D5C1-4D6D-4F11-BA18-09645919EE7E", "BB3F8E59-845E-4D0A-BEE2-30D270EAC5CD" ] }, "name": "14Days" }, { "description": "Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.", "eMeasureUuids": { "initialPopulationUuid": "6492A3E6-D8C8-40A1-B280-909DB3436D1E", "denominatorUuid": "1F384AE6-DC33-4464-A743-D883C75BDCE9", "numeratorUuid": "3C89FB2F-3335-4384-8F25-FB58A1B00AE3", "denominatorExclusionUuid": "353DB0FA-5117-40DD-A989-8FA220D184BC", "strata": [ "E96FDC2B-1E60-41FE-A93D-ED20407BFDB5", "54B42C7D-4F4D-4F6B-BCB8-920B974DFC9C", "6834216F-BB45-4BFE-B326-5D710D33E041" ] }, "name": "34Days" } ], "eMeasureUuid": "2c928084-82ea-d7c5-0182-ec98d1c20129" }, { "title": "Follow-Up Care for Children Prescribed ADHD Medication (ADD)", "eMeasureId": "CMS136v13", "nqfEMeasureId": null, "nqfId": null, "measureId": "366", "description": "Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. \na) Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.\nb) Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0136v13" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "description": "Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.", "eMeasureUuids": { "initialPopulationUuid": "9B70E808-0E6B-44FB-AC46-0548A1E409DE", "denominatorUuid": "886B4ABD-BEB6-43DC-90AE-C529F5E07B47", "numeratorUuid": "FD0D1365-F405-4A66-9B7A-2ABE64033E8A", "denominatorExclusionUuid": "00B7D640-5DD7-41D1-BF47-B95A2C19B6D7" }, "name": "30Days" }, { "description": "Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.", "eMeasureUuids": { "initialPopulationUuid": "72606B57-2F1C-40B4-9655-F691A594A611", "denominatorUuid": "F6EA0497-C79C-4722-838F-528A8635F1BE", "numeratorUuid": "0DFDC593-66E3-4532-9F27-6C5C6C947EE5", "denominatorExclusionUuid": "CD78A07D-8D5B-4E22-B05E-9A569B2FC375" }, "name": "overall" } ], "eMeasureUuid": "2c928084-8211-3ece-0182-1de98c500310" }, { "title": "Depression Remission at Twelve Months", "eMeasureId": "CMS159v12", "nqfEMeasureId": "0710e", "nqfId": "0710", "measureId": "370", "description": "The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_370_MIPSCQM.pdf", "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0159v12" }, "overallAlgorithm": "weightedAverage", "strata": [ { "description": "Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5", "eMeasureUuids": { "initialPopulationUuid": "E4E92400-0CE1-403C-818D-EF5C25A952AA", "denominatorUuid": "4B7B1714-FE42-40EB-A652-7C077636A8BF", "numeratorUuid": "8A5DE292-E5E6-45CE-99C6-22E6F8E688E4", "denominatorExclusionUuid": "4539BAD0-93C8-4606-B167-91086446F8D8", "strata": [ "16B03548-4E23-4D9B-B1C6-F7D3DC6F1727", "B44C46D8-64D6-405B-8283-981CDC1D6E5E" ] }, "name": "adolescents" }, { "name": "adults", "description": "Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5" } ], "eMeasureUuid": "2c928082-86db-6718-0187-0ad80afa0a7e" }, { "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "eMeasureId": "CMS177v12", "nqfEMeasureId": null, "nqfId": null, "measureId": "382", "description": "Percentage of patient visits for those patients aged 6 through 16 years at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk", "measureType": "process", "isHighPriority": true, "primarySteward": "Mathematica", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2024/cms0177v12" }, "eMeasureUuid": "2c928084-82ea-d7c5-0182-ff64c38d094f", "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "2A6F66CE-9C98-471E-93C7-5C8A67261CDD", "denominatorUuid": "913060C1-BAAB-456E-99C5-A6B9662CC06E", "numeratorUuid": "9C5E92E5-D8B5-4DC9-9021-195E264FB2E0" } } ] }, { "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "measureId": "383", "description": "Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.", "measureType": "intermediateOutcome", "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_383_MIPSCQM.pdf" } }, { "title": "Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "468", "description": "Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.", "measureType": "process", "isHighPriority": true, "primarySteward": "University of Southern California", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "physicalMedicine" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_468_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_MIPSCQM.pdf" } }, { "title": "Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "502", "description": "The percentage of individuals aged 18 and older with a mental and/or substance use disorder who demonstrated improvement or maintenance of functioning based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) or Sheehan Disability Index (SDS) 30 to 180 days after an index assessment.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_502_MIPSCQM.pdf" } }, { "title": "Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "504", "description": "Percentage of adult aged 18 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.", "measureType": "process", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "multiPerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M0005", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_504_MIPSCQM.pdf" }, "overallAlgorithm": "overallStratumOnly", "strata": [ { "name": "24hour", "description": "Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter)" }, { "name": "overall", "description": "Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation." } ] }, { "title": "Reduction in Suicidal Ideation or Behavior Symptoms", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "505", "description": "The percentage of patients aged 18 and older with a mental and/or substance use disorder AND suicidal thoughts, behaviors or risk symptoms who demonstrated a reduction in suicidal ideation and/or behavior symptoms based on results from the Columbia-Suicide Severity Rating Scale (C-SSRS) 'Screen Version' or 'Since Last Visit' within 120 days after an index assessment.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_505_MIPSCQM.pdf" } }, { "measureId": "MBHR2", "title": "Anxiety Response at 6-months", "description": "The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment (GAD-7 score at least 25% less than score at index event) at 6-months (+/- 60 days) after an index visit.", "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "firstPerformanceYear": 2018, "allowedVendors": [ "4067715" ], "allowedPrograms": [ "mips", "pcf", "M1369" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] }, { "measureId": "MBHR7", "title": "Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children", "description": "The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event AND with documentation of a standardized symptom monitor (PCL-5 for adults, CATS for child/adolescent) AND demonstrated a response to treatment at six months (+/- 120 days) after the index visit.\n\nThis measure is a multi-strata measure, which addresses symptom monitoring for both child and adult patients being treated for post-traumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.", "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "isInverse": false, "isRiskAdjusted": false, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "firstPerformanceYear": 2020, "allowedVendors": [ "4067715" ], "allowedPrograms": [ "mips", "pcf", "M1369" ], "category": "quality", "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "measureSets": [], "isRegistryMeasure": true, "isIcdImpacted": false, "metricType": "registrySinglePerformanceRate", "submissionMethods": [ "registry" ] } ], "iaMeasures": [ { "category": "ia", "title": "Enhance Engagement of Medicaid and Other Underserved Populations", "description": "To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat data (i.e., data measuring the time between clinician identifying a need for an appointment and the patient having a scheduled appointment) to identify patterns by which care or engagement with Medicaid patients or other groups of underserved patients has not achieved standard practice guidelines; and with this information, create, implement, and monitor an approach for improvement. This approach may include screening for patient barriers to treatment, especially transportation barriers, and providing resources to improve engagement (e.g., state Medicaid non-emergency medical transportation benefit).", "measureId": "IA_AHE_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1368", "M1369" ] }, { "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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "category": "ia", "title": "MIPS Eligible Clinician Leadership in Clinical Trials or CBPR", "description": "Lead clinical trials, research alliances, or community-based participatory research (CBPR) that identify tools, research, or processes that focus on minimizing disparities in healthcare access, care quality, affordability, or outcomes. Research could include addressing health-related social needs like food insecurity, housing insecurity, transportation barriers, utility needs, and interpersonal safety.", "measureId": "IA_AHE_5", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1367", "M1368", "M1369" ] }, { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0055", "G0058", "M0005", "M1369" ] }, { "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", "pcf", "app1", "M0002", "M0003", "M0004", "M1366", "M1369" ] }, { "category": "ia", "title": "Integration of patient coaching practices between visits", "description": "Provide coaching between visits with follow-up on care plan and goals.", "measureId": "IA_BE_23", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "pcf", "app1", "M1369" ] }, { "category": "ia", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women", "description": "Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.", "measureId": "IA_BMH_14", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1369" ] }, { "category": "ia", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults", "description": "Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.", "measureId": "IA_BMH_15", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M1369" ] }, { "category": "ia", "title": "MDD prevention and treatment interventions", "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.", "measureId": "IA_BMH_5", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "M1369" ] }, { "category": "ia", "title": "Implementation of Integrated Patient Centered Behavioral Health Model", "description": "Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following: • Use evidence-based treatment protocols and treatment to goal where appropriate;• Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;• Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;• Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;• Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;• Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or• Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.", "measureId": "IA_BMH_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "M1369" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "category": "ia", "title": "Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)", "description": "Address inequities in health outcomes by using population health data analysis tools to identify health inequities in the community and practice and assess options for effective and relevant interventions such as Population Health Toolkit or other resources identified by the clinician, practice, or by CMS. Based on this information, create, refine, and implement an action plan to address and close inequities in health outcomes and/or health care access, quality, and safety.", "measureId": "IA_PM_6", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "pcf", "app1", "M1366", "M1368", "M1369" ] }, { "category": "ia", "title": "Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support", "description": "In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain via clinical decision support (CDS). For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.", "measureId": "IA_PSPA_32", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "M1368", "M1369" ] } ], "costMeasures": [ { "category": "cost", "title": "Depression", "description": "Patients receiving medical care to manage and treat depression. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Depression episode.", "measureId": "COST_DEP_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "M0005", "M1369" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-depression-v2.pdf" } }, { "category": "cost", "title": "Psychoses and Related Conditions", "description": "Patients who receive inpatient treatment for psychoses or related conditions during the performance period. Acute IP hospitals and inpatient psychiatric facilities (IPFs).", "measureId": "COST_PRC_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "M1369" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-psych-v2.pdf" } }, { "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/2023-12-18-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "app1", "G0055", "G0059", "M0003", "M0004", "M1366", "M1367", "M1369" ] } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": 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The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_220_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Shoulder Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "221", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in FS is assessed using the FOTO Shoulder FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_221_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "222", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the FOTO Elbow/Wrist/Hand FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_222_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Neck Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "478", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_478_MIPSCQM.pdf" } }, { "title": "Screening for Social Drivers of Health", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "487", "description": "Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.", "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "chiropracticMedicine", "clinicalSocialWork", "dermatology", "emergencyMedicine", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_487_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", "pcf", "app1", "G0055", "G0057", "M0005", "M1366", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0058", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370" ] }, { "category": "ia", "title": "Provide Education Opportunities for New Clinicians", "description": "MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.", "measureId": "IA_AHE_6", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "M1370" ] }, { "category": "ia", "title": "Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols", "description": "Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:•\tUse Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.•\tUpdate and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.•\tUpdate and apply requirements for staff training on food security and nutrition.•\tUpdate and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening. Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.", "measureId": "IA_AHE_9", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "achievingHealthEquity", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "G0055", "M0002", "M0005", "M1366", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1370" ] }, { "category": "ia", "title": "Promoting Clinician Well-Being", "description": "Develop and implement programs to support clinician well-being and resilience—for example, through relationship-building opportunities, leadership development plans, or creation of a team within a practice to address clinician well-being—using one of the following approaches:•\tCompletion of clinician survey on clinician well-being with subsequent implementation of an improvement plan based on the results of the survey.•\tCompletion of training regarding clinician well-being with subsequent implementation of a plan for improvement.", "measureId": "IA_BMH_12", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "G0057", "M0001", "M1370" ] }, { "category": "ia", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults", "description": "Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.", "measureId": "IA_BMH_15", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "pcf", "app1", "G0054", "M1369", "M1370" ] }, { "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", "pcf", "app1", "M0001", "M0003", "M0004", "M1367", "M1370" ] }, { "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", "pcf", "app1", "M1370" ] }, { "category": "ia", "title": "Implementation of documentation improvements for practice/process improvements", "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).", "measureId": "IA_CC_8", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "pcf", "app1", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0059", "M0001", "M0003", "M0004", "M0005", "M1367", "M1368", "M1370" ] }, { "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", "pcf", "app1", "G0053", "M0001", "M0003", "M0004", "M1366", "M1369", "M1370" ] }, { "category": "ia", "title": "Collection and use of patient experience and satisfaction data on access", "description": "Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.", "measureId": "IA_EPA_3", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "pcf", "app1", "M1370" ] }, { "category": "ia", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "measureId": "IA_MVP", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "weight": "high", "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "category": "ia", "title": "Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.", "description": "Use decision support - ideally platform-agnostic, interoperable clinician decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs. Clinicians should focus on utilizing open-source, freely available, interoperable CDS in completing the requirements of this activity.", "measureId": "IA_PSPA_16", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "pcf", "app1", "G0059", "M0001", "M0002", "M1370" ] }, { "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", "pcf", "app1", "M0003", "M0004", "M1370" ] } ], "costMeasures": [ { "category": "cost", "title": "Low Back Pain", "description": "Patients receiving medical care to manage and treat low back pain. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Low Back Pain episode.", "measureId": "COST_LBP_1", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "overallAlgorithm": "simpleAverage", "submissionMethods": [ "administrativeClaims" ], "allowedPrograms": [ "mips", "app1", "M1370" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2023-12-05-mif-ebcm-low-back-v2.pdf" } } ], "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/2024MIPSPIMeasuresEPrescribing.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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 does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs 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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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/2024MIPSPIMeasuresImmunizationRegistryReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ] }, { "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/2024MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "preprod": [] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "SAFER Guides High Priority Practices Guide", "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/2024MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, "allowedPrograms": [ "mips", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "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", "companionMeasureId": [], "allowedPrograms": [ "mips", "pcf", "app1", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0003", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ], "administrativeClaimsMeasures": [] } ]