[ { "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", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Rheumatology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "039", "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "description": "Percentage of women aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) test to check for osteoporosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M1366" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_039_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_039_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "176", "title": "Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "infectiousDisease", "internalMedicine", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_176_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "177", "title": "Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity", "description": "Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart 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 performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2523", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_177_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "178", "title": "Rheumatoid Arthritis (RA): Functional Status Assessment", "description": "Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart for whom a functional status assessment was performed at least once during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_178_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "180", "title": "Rheumatoid Arthritis (RA): Glucocorticoid Management", "description": "Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart 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 during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_180_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "493", "title": "Adult Immunization Status", "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; pneumococcal; and hepatitis B.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_493_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" }, "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 2 doses of the herpes zoster recombinant vaccine anytime on October 20, 2017, through the end of the measurement period." }, { "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 19th birthday and before the end of the measurement period." }, { "name": "hepB", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who were administered a hepatitis B vaccine series." } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "ACR10", "title": "Hepatitis B Safety Screening", "description": "If a patient is newly initiating biologic OR new synthetic DMARD therapy (e.g. methotrexate, leflunomide, etc.), then the medical record should indicate appropriate screening for hepatitis B in the preceding 12 month period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "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 an active 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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1649514" ] }, { "category": "quality", "measureId": "UREQA9", "title": "Screening for Osteoporosis for Men Aged 70 Years and Older", "description": "Percentage of male patients aged 70 years and older who had a central dual-energy X-ray absorptiometry (DXA) to screen for osteoporosis \n\n\nReporting Frequency:\nThis measure is reported once per reporting period", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1649514" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_1", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_24", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "M0001", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_25", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M1420" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0059", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_28", "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).", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_RA_1", "title": "Rheumatoid Arthritis episode-based cost measure", "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.\nThe Rheumatoid Arthritis episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat rheumatoid arthritis. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Rheumatoid Arthritis episode", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-rheum-arth.pdf" }, "allowedPrograms": [ "mips", "G0053" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case 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"M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "G0054", "clinicalTopic": "Stroke Care and Prevention", "title": "Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes", "description": "The Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP focuses on the clinical theme of providing fundamental prevention and treatment of those patients at risk for or that have had a stroke.", "specialtiesMostApplicableTo": [ "Neurology", "Neurosurgical", "Vascular Surgery", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Stroke Care and Prevention", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "187", "title": "Stroke and Stroke Rehabilitation: Thrombolytic Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "emergencyMedicine", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_187_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "236", "title": "Controlling High Blood Pressure", "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS165v14", "eMeasureUuid": "cd9a5c8e-ac16-4e10-a1f4-4dfe48e02cab", "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "236SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0002", "M0005" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0165v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_236_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_236_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "A35D89C5-C903-4D4C-BDBC-EA70D1254BEF", "denominatorUuid": "FECE5EB1-842C-42B6-B2BC-7035C79222E4", "numeratorUuid": "73661F57-1A94-4982-8136-EDCE51A9AEA8", "denominatorExclusionUuid": "8D42520C-8C19-47AF-B3E7-A66EAECA0DBD" } } ] }, { "category": "quality", "measureId": "326", "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_326_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "344", "title": "Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "description": "Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) without major complication who are discharged to home no later than post-operative day #2.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society for Vascular Surgery", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "neurosurgical", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_344_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "413", "title": "Door to Puncture Time for Endovascular Stroke Treatment", "description": "Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_413_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "438", "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS347v9", "eMeasureUuid": "22ea0c5f-5a85-422b-8089-91c24c31bcbb", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M0005", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0347v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_438_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: - All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR - 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; OR - Patients aged 40-75 years with a diagnosis of diabetes; OR - Patients aged 40 to 75 with a 10-year ASCVD risk score of >= 20 percent.", "eMeasureUuids": { "initialPopulationUuid": "DC7EE1FA-285A-447A-AB71-621A180BECBB", "denominatorUuid": "F5A7F615-7471-4549-88FD-C8B447C9685F", "numeratorUuid": "E87BD132-0762-43F1-B61F-427E13BBE7FD", "denominatorExceptionUuid": "5F2E3CBA-C623-492F-8590-A298A5A5240D", "denominatorExclusionUuid": "589CFFC5-DA6E-4A83-822F-97A5025D400B" } } ] }, { "category": "quality", "measureId": "441", "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "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:\n• Most recent blood pressure (BP) measurement is less than or equal to 130/80 mm Hg -- AND\n• Most recent tobacco status is Tobacco Free -- AND\n• Daily Aspirin or Other Antiplatelet Unless Contraindicated – AND\n• High Intensity Statin Use Unless Contraindicated", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_441_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "495", "title": "Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood", "description": "The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3665", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Hospice and Palliative Medicine (AAHPM)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "neurology", "oncology", "pulmonology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_495_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "heard", "description": "Patient felt heard and understood by this provider and team" }, { "name": "bestInterest", "description": "Patient felt this provider and team put my best interests first when making recommendations about my care" }, { "name": "seen", "description": "Patient felt this provider and team saw me as a person, not just someone with a medical problem" }, { "name": "understood", "description": "Patient felt this provider and team understood what is important to me in my life" } ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_1", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_24", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "M0001", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M1369", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_17", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1423", "M1425", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_IHCI_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ich-cva.pdf" }, "allowedPrograms": [ "mips", "G0054", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Heart Disease", "hasCahps": false, "hasOutcomeAdminClaims": true, "qualityMeasures": [ { "category": "quality", "measureId": "005", "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)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS135v14", "eMeasureUuid": "c41e2269-718d-40d9-bda2-a6cc80b44763", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "hospitalists", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0135v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_005_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "387A9670-3826-437F-99C6-436D51ECA38B", "denominatorUuid": "7F599BDC-FDC8-4139-BE0C-9DE81B1FA01B", "numeratorUuid": "19BD56A6-3838-4888-9780-1B284DFE6C45", "denominatorExceptionUuid": "D3887622-BD0C-4965-B2E4-3C58A3F2550F", "denominatorExclusionUuid": "F2B96014-C3D2-4F0B-BA16-8B93747A04E8" } } ] }, { "category": "quality", "measureId": "006", "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0067", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_006_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "007", "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS145v14", "eMeasureUuid": "5f7dd8a7-07b4-4271-81ff-3e0ab486cae7", "nqfEMeasureId": "0070e", "nqfId": "0070", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0145v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_007_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with left ventricular systolic dysfunction (LVEF <=40%) - Population 2: Patients with a prior (within the past 3 years) myocardial infarction For the purposes of this measure, a single performance rate can be calculated as follows: Performance Rate = (Numerator 1 + Numerator 2)/ [(Denominator 1 - Denominator Exceptions 1) + (Denominator 2 - Denominator Exceptions 2)]", "eMeasureUuids": { "initialPopulationUuid": "A8E96013-BA2C-445F-8084-5610925F378A", "denominatorUuid": "412A6DD3-1582-43EE-9E7E-BA55261D5485", "numeratorUuid": "1A0759C1-708C-4DC9-B3F4-5D8EAC1BA579", "denominatorExceptionUuid": "A25F0F00-D7D5-44AA-A335-36E844CB96AD" } } ] }, { "category": "quality", "measureId": "008", "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS144v14", "eMeasureUuid": "36fb771e-e488-4e62-9a46-fe4cd390c801", "nqfEMeasureId": "0083e", "nqfId": "0083", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "hospitalists", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0144v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_008_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were prescribed or already taking beta-blocker therapy during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "EF7BEF3F-81C2-475F-96C7-2FC7F741FB4D", "denominatorUuid": "2C681E01-0A30-437E-A0C3-953EF766E5E7", "numeratorUuid": "AC0D26F8-7DE1-42F6-9CD9-2B96D8383E51", "denominatorExceptionUuid": "E3081257-80AD-420A-98D4-EA2629C32C0E", "denominatorExclusionUuid": "686A54E2-2D9C-423B-B3C5-31C9AECCFA73" } } ] }, { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "118", "title": "Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0066", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "endocrinology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_118_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "128", "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if BMI was outside of normal parameters.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS69v14", "eMeasureUuid": "6eabf62a-209b-4969-829e-04c502db761d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "G0055", "G0058", "M1367", "M1370", "M1424" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0069v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_128_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_128_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5A321168-A454-4BD9-B82E-A403B009DE8F", "denominatorUuid": "7980B172-09ED-4A0C-B29C-D652DB845BF5", "numeratorUuid": "5AF09C9B-07A3-4BF4-A366-7AEA9C934050", "denominatorExceptionUuid": "5509373E-4ACA-4B71-8E56-E42BBB1A3880", "denominatorExclusionUuid": "50128A04-F2DD-4B6D-A078-B16904431CEC" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "238", "title": "Use of High-Risk Medications in Older Adults", "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS156v14", "eMeasureUuid": "24a5b98e-0bba-44fb-86ff-fcb3f45c0fc4", "nqfEMeasureId": null, "nqfId": "0022", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055", "M0004", "M1421" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "geriatrics", "internalMedicine", "oncology", "ophthalmology", "optometry", "otolaryngology", "pulmonology", "rheumatology", "skilledNursingFacility", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0156v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_238_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F8EF7E4A-80B9-4A74-8461-498D79DA5442", "denominatorUuid": "D1555193-7364-45F6-94A6-F1DC2E78C197", "numeratorUuid": "466F79E9-53CB-427E-AB56-2ACFA1969921", "denominatorExclusionUuid": "A8A6B357-128E-4A03-B7E7-D1BFAB85700B" }, "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": "C3552CAC-11F6-4E4E-89D9-F3999A3B9A3B", "denominatorUuid": "FA269FE8-A1D6-4FC0-9CD2-1AA5E1641CB5", "numeratorUuid": "3751D444-5C47-4D54-BEFE-40BAD4E0EB3F", "denominatorExclusionUuid": "FB873FB8-D7A3-4A72-874F-56852D6312E5" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "CEDAD393-CD57-48F9-979A-C33B9875254C", "denominatorUuid": "A30044E2-4C59-4E0B-A5FD-7553FFA7E851", "numeratorUuid": "14000C16-CD29-44E8-BE5C-D94DED574293", "denominatorExclusionUuid": "154B3202-22A5-4515-B86F-2C7EBB5342DF" }, "name": "totalRate" } ] }, { "category": "quality", "measureId": "243", "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0643", "measureType": "process", "isHighPriority": true, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_243_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "326", "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_326_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "377", "title": "Functional Status Assessments for Heart Failure", "description": "Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS90v15", "eMeasureUuid": "fb7a03c0-e898-40a5-8132-f692ce583c54", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0090v15" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "B3F0E1F2-9645-402E-8A3E-414E9773BC85", "denominatorUuid": "80370B8C-F59E-4548-B7FA-65BC1B3B83DA", "numeratorUuid": "EDC19F9D-D470-477C-AC64-6ED092F4EBE2", "denominatorExclusionUuid": "C19395B9-D760-45FD-A850-539F0BE7F6D7" } } ] }, { "category": "quality", "measureId": "392", "title": "Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", "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", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_392_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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" } ] }, { "category": "quality", "measureId": "393", "title": "Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", "description": "Infection rate following CIED device implantation, replacement, or revision.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_393_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "441", "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "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:\n• Most recent blood pressure (BP) measurement is less than or equal to 130/80 mm Hg -- AND\n• Most recent tobacco status is Tobacco Free -- AND\n• Daily Aspirin or Other Antiplatelet Unless Contraindicated – AND\n• High Intensity Statin Use Unless Contraindicated", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_441_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "495", "title": "Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood", "description": "The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3665", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Hospice and Palliative Medicine (AAHPM)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "neurology", "oncology", "pulmonology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_495_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "heard", "description": "Patient felt heard and understood by this provider and team" }, { "name": "bestInterest", "description": "Patient felt this provider and team put my best interests first when making recommendations about my care" }, { "name": "seen", "description": "Patient felt this provider and team saw me as a person, not just someone with a medical problem" }, { "name": "understood", "description": "Patient felt this provider and team understood what is important to me in my life" } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_24", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "M0001", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_25", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M1420" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "M0001", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_4", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_EOPCI_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-op-pci.pdf" }, "allowedPrograms": [ "mips", "G0055" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_HF_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-heart-fail.pdf" }, "allowedPrograms": [ "mips", "G0055", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_STEMI_1", "title": "Inpatient Percutaneous Coronary Intervention (PCI) episode-based cost measure", "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.\nThe Inpatient PCI episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who present with a cardiac event and 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.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ip-pci.pdf" }, "allowedPrograms": [ "mips", "G0055" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", 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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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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"M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [ { "category": "quality", "measureId": "492", "title": "Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "N/A", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/492_PY2026-MIPS-Admin-Claims-HF-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] } ] }, { "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", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Emergency Medicine", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "065", "title": "Appropriate Treatment for Upper Respiratory Infection (URI)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS154v14", "eMeasureUuid": "22233707-222d-473d-9acb-8ef6cedd0690", "nqfEMeasureId": null, "nqfId": "0069", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "infectiousDisease", "pediatrics", "urgentCare" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0154v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_065_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection", "eMeasureUuids": { "initialPopulationUuid": "50D6E6FD-F841-4E7C-9719-CD484A43AC8A", "denominatorUuid": "5DB707B9-4D8B-4CAF-B8AB-4310B02681D0", "numeratorUuid": "824D23C2-A5B6-472D-BF80-C01FDCE067B5", "denominatorExclusionUuid": "932D4556-8347-4562-9B3A-179FD75D7317", "strata": [ "ecc38660-2537-4dbf-9432-cb8d21bed027", "5040441a-d27d-451b-b610-888525d40317", "a65aac60-e26a-4e79-a358-eead473ed112" ] } } ] }, { "category": "quality", "measureId": "116", "title": "Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0058", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "pediatrics", "preventiveMedicine", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_116_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "321", "title": "CAHPS for MIPs Clinician/Group Survey", "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 CBE 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 CBE)\n• How well Providers Communicate; (Not endorsed by CBE)\n• Patient’s Rating of Provider; (CBE endorsed # 0005)\n• Access to Specialists; (Not endorsed by CBE)\n• Health Promotion and Education; (Not endorsed by CBE)\n• Shared Decision-Making; (Not endorsed by CBE) \n• Health Status and Functional Status; (Not endorsed by CBE)\n• Courteous and Helpful Office Staff; (CBE endorsed # 0005)\n• Care Coordination; (Not endorsed by CBE)\n• Stewardship of Patient Resources. (Not endorsed by CBE)", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M0005", "M1423", "M1503" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {}, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "331", "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_331_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "415", "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_415_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "416", "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_416_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "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", "metricType": "nonProportion", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP52", "title": "Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Acute 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, atraumatic low back pain.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371" ] }, { "category": "quality", "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", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "5133825", "4757099" ] }, { "category": "quality", "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", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "5133825", "1718371" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_EDV_1", "title": "Emergency Medicine", "description": "Patients who have an Emergency Department (ED) during the year.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-emergency.pdf" }, "allowedPrograms": [ "mips", "G0057" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Lower Extremity Joint Repair", "hasCahps": false, "hasOutcomeAdminClaims": true, "qualityMeasures": [ { "category": "quality", "measureId": "024", "title": "Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "interventionalRadiology", "orthopedicSurgery", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_024_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_024_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "128", "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if BMI was outside of normal parameters.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS69v14", "eMeasureUuid": "6eabf62a-209b-4969-829e-04c502db761d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "G0055", "G0058", "M1367", "M1370", "M1424" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0069v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_128_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_128_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5A321168-A454-4BD9-B82E-A403B009DE8F", "denominatorUuid": "7980B172-09ED-4A0C-B29C-D652DB845BF5", "numeratorUuid": "5AF09C9B-07A3-4BF4-A366-7AEA9C934050", "denominatorExceptionUuid": "5509373E-4ACA-4B71-8E56-E42BBB1A3880", "denominatorExclusionUuid": "50128A04-F2DD-4B6D-A078-B16904431CEC" } } ] }, { "category": "quality", "measureId": "350", "title": "Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_350_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "351", "title": "Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", "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).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_351_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "376", "title": "Functional Status Assessment for Total Hip Replacement", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS56v14", "eMeasureUuid": "9cf0729d-8107-4695-9b3a-e58d332647c0", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0056v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "181C14DB-225A-4C87-8D98-517D263B40BB", "denominatorUuid": "DCF64C7D-CF13-4450-830A-6734D90B17FF", "numeratorUuid": "061C67F7-3CE9-4703-A3DB-BC9D3596FB05", "denominatorExclusionUuid": "BF3BAA2C-9FC1-488C-8FBA-FB61D401B534" } } ] }, { "category": "quality", "measureId": "470", "title": "Functional Status After Primary Total Knee Replacement", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_470_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "G0059", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_7", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1422", "M1423", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_18", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1499", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_KA_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-knee-arthro.pdf" }, "allowedPrograms": [ "mips", "G0058" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_PHA_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-el-ha.pdf" }, "allowedPrograms": [ "mips", "G0058" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", 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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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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"M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [ { "category": "quality", "measureId": "480", "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)", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3493", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/480_MIPS_THA_TKA_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ] }, { "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", "Nonphysician Practitioners", "Certified Registered Nurse Anesthetists", "Physician Assistants" ], "clinicalTopics": "Anesthesia", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "404", "title": "Anesthesiology Smoking Abstinence", "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_404_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "430", "title": "Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_430_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "463", "title": "Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_463_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "477", "title": "Multimodal Pain Management", "description": "Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_477_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "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).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "ABG QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "9181695", "7418330" ] }, { "category": "quality", "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.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "9181695", "7418330" ], "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." } ] }, { "category": "quality", "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", "metricType": "nonProportion", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Anesthesia Quality Registry (AQR QCDR) in Collaboration with Anesthesia Quality Institute (AQI) and American Society of Anesthesiologists (ASA)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6775913", "5551268", "6169123", "7418330" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_22", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0059", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "G0059", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_19", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M0001", "M0002", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Oncology and Hematology", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "102", "title": "Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients", "description": "Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS129v15", "eMeasureUuid": "360c2fd5-5a41-49cc-b83c-78f6225b8145", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "oncology", "radiationOncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0129v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_102_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who did not have a bone scan performed after diagnosis of prostate cancer and before the end of the measurement period", "eMeasureUuids": { "initialPopulationUuid": "BD03BE75-BCC3-40EB-A93B-2085A1F53A7B", "denominatorUuid": "0E621B55-8522-4202-944F-CCB1DD58D373", "numeratorUuid": "FA99F264-3BD5-4B71-BF14-7AE4B2A4967F", "denominatorExceptionUuid": "6CC0BCC3-733E-4A1A-A7A0-9F4D374FBFB4" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "143", "title": "Oncology: Medical and Radiation - Pain Intensity Quantified", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS157v14", "eMeasureUuid": "eef8545a-a52c-4352-9e38-e72fa5da0065", "nqfEMeasureId": "0384e", "nqfId": "0384", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0157v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_143_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry", "electronicHealthRecord" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Visits for patients with a diagnosis of cancer who are currently receiving chemotherapy - Population 2: Visits for patients with a diagnosis of cancer who are currently receiving radiation therapy For the purposes of this measure, a single performance rate can be calculated as follows: Performance Rate = (Numerator 1 + Numerator 2)/ (Denominator 1 + Denominator 2)", "eMeasureUuids": { "initialPopulationUuid": "F7415275-1792-42E9-B06D-7940E5F07FEC", "denominatorUuid": "B174B06F-70E3-4E8D-B173-F12DC08FAFB4", "numeratorUuid": "9E2746AB-7FFE-47BD-A962-1F458BEBD694" } } ] }, { "category": "quality", "measureId": "144", "title": "Oncology: Medical and Radiation - Plan of Care for Pain", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0383", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_144_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "321", "title": "CAHPS for MIPs Clinician/Group Survey", "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 CBE 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 CBE)\n• How well Providers Communicate; (Not endorsed by CBE)\n• Patient’s Rating of Provider; (CBE endorsed # 0005)\n• Access to Specialists; (Not endorsed by CBE)\n• Health Promotion and Education; (Not endorsed by CBE)\n• Shared Decision-Making; (Not endorsed by CBE) \n• Health Status and Functional Status; (Not endorsed by CBE)\n• Courteous and Helpful Office Staff; (CBE endorsed # 0005)\n• Care Coordination; (Not endorsed by CBE)\n• Stewardship of Patient Resources. (Not endorsed by CBE)", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M0005", "M1423", "M1503" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {}, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "450", "title": "Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer", "description": "Percentage of patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_450_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "451", "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", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor (EGFR) monoclonal antibody (MoAb) therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed before initiation of anti-EGFR MoAb.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1859", "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_451_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "453", "title": "Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)", "description": "Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0210", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_453_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "457", "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)", "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_457_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "462", "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": "CMS645v9", "eMeasureUuid": "4536b54a-8ef4-418a-8944-d1426c6a58de", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Oregon Urology Institute", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "endocrinology", "oncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0645v9" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "786E05E4-F16E-492D-BAD4-2555F1CA3F40", "denominatorUuid": "B876332D-519E-444E-839F-7FA9C919F1A6", "numeratorUuid": "474E39BC-B7EA-4BBA-A7ED-62D50806F61D", "denominatorExceptionUuid": "34047550-15EF-4204-9A8F-A0285CFE8F4F" } } ] }, { "category": "quality", "measureId": "490", "title": "Appropriate Intervention of Immune-related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Society for Immunotherapy of Cancer (SITC)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_490_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "495", "title": "Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood", "description": "The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3665", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Hospice and Palliative Medicine (AAHPM)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "neurology", "oncology", "pulmonology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_495_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "heard", "description": "Patient felt heard and understood by this provider and team" }, { "name": "bestInterest", "description": "Patient felt this provider and team put my best interests first when making recommendations about my care" }, { "name": "seen", "description": "Patient felt this provider and team saw me as a person, not just someone with a medical problem" }, { "name": "understood", "description": "Patient felt this provider and team understood what is important to me in my life" } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "506", "title": "Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of metastatic non-small cell lung cancer (NSCLC) or squamous cell carcinoma of head and neck (HNSCC) on first-line immune checkpoint inhibitor (ICI) therapy, who had a positive PD-L1 biomarker expression test result prior to giving ICI therapy.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Society for Immunotherapy of Cancer (SITC)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_506_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "507", "title": "Appropriate Germline Testing for Ovarian Cancer Patients", "description": "Percentage of patients, aged 18 and older, diagnosed with epithelial ovarian, fallopian tube, or primary peritoneal cancer who undergo germline testing within 6 months of diagnosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_507_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "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", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH17", "title": "Oncology: Utilization of Prophylactic GCSF for Cancer Patients Receiving Low-Risk Chemotherapy (inverse measure)", "description": "Percentage of patients with cancer (solid tumors only) receiving any white cell growth factors with during the first cycle of low-risk chemotherapy.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_24", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "M0001", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_17", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1423", "M1425", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "M0001", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_21", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M0004", "M1423", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_13", "title": "Participation in Joint Commission Evaluation Initiative", "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M0001", "M0002", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_28", "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).", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_PC_1", "title": "Prostate Cancer episode-based cost measure", "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.\nThe Prostate Cancer episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat prostate cancer. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Prostate Cancer episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-prost-ca.pdf" }, "allowedPrograms": [ "mips", "M0001", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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": [ { "category": "quality", "measureId": "001", "title": "Diabetes: Glycemic Status Assessment Greater Than 9%", "description": "Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS122v14", "eMeasureUuid": "9700a8b9-9f65-41a8-8464-1da26cda857b", "nqfEMeasureId": null, "nqfId": "0059", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "001SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0005", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0122v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_001_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_001_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "51D8CA9A-E511-4793-8AD4-EFAE90F3ABA4", "denominatorUuid": "EA65F958-962E-433B-A9A3-CC2EA7B76E26", "numeratorUuid": "10C65EBE-685C-48F8-8B24-351C6F3481E9", "denominatorExclusionUuid": "CA386077-1F7A-4C23-85D7-33A4FCED0803" } } ] }, { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "236", "title": "Controlling High Blood Pressure", "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS165v14", "eMeasureUuid": "cd9a5c8e-ac16-4e10-a1f4-4dfe48e02cab", "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "236SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0002", "M0005" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0165v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_236_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_236_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "A35D89C5-C903-4D4C-BDBC-EA70D1254BEF", "denominatorUuid": "FECE5EB1-842C-42B6-B2BC-7035C79222E4", "numeratorUuid": "73661F57-1A94-4982-8136-EDCE51A9AEA8", "denominatorExclusionUuid": "8D42520C-8C19-47AF-B3E7-A66EAECA0DBD" } } ] }, { "category": "quality", "measureId": "482", "title": "Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate", "description": "Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_482_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "488", "title": "Kidney Health Evaluation", "description": "Percentage of patients aged 18--85 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 performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": "CMS951v4", "eMeasureUuid": "79d13667-8fea-4cf6-bf7b-98966acb0eb5", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Kidney Foundation", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "preventiveMedicine", "urgentCare", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0951v4", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_488_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who received a kidney health evaluation during the measurement period. Kidney health evaluation is defined by an eGFR AND uACR within the measurement period OR an eGFR and a Urine Albumin and Urine Creatine result documented less than or equal to four days apart", "eMeasureUuids": { "initialPopulationUuid": "38EEC8FC-7350-4F83-B58E-79DC9515423D", "denominatorUuid": "611F9C98-6875-40C3-BC40-D6BDA58640E6", "numeratorUuid": "9CCB6F0C-DA06-40C0-AB1A-D38DD8EF34C9", "denominatorExclusionUuid": "D07D6FCB-7FC7-4226-B930-913E559D33AD" } } ] }, { "category": "quality", "measureId": "489", "title": "Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", "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 the 12-month measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1662", "measureType": "process", "isHighPriority": false, "primarySteward": "Renal Physicians Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "geriatrics", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_489_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "493", "title": "Adult Immunization Status", "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; pneumococcal; and hepatitis B.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_493_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" }, "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 2 doses of the herpes zoster recombinant vaccine anytime on October 20, 2017, through the end of the measurement period." }, { "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 19th birthday and before the end of the measurement period." }, { "name": "hepB", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who were administered a hepatitis B vaccine series." } ] }, { "category": "quality", "measureId": "495", "title": "Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood", "description": "The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3665", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Hospice and Palliative Medicine (AAHPM)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "neurology", "oncology", "pulmonology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_495_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "heard", "description": "Patient felt heard and understood by this provider and team" }, { "name": "bestInterest", "description": "Patient felt this provider and team put my best interests first when making recommendations about my care" }, { "name": "seen", "description": "Patient felt this provider and team saw me as a person, not just someone with a medical problem" }, { "name": "understood", "description": "Patient felt this provider and team understood what is important to me in my life" } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "510", "title": "First Year Standardized Kidney Transplant Waitlist Ratio (FYSWR)", "description": "The number of newly initiated patients on dialysis in a practitioner group who are under the age of 75 and were either listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant within the first year of initiating dialysis. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.", "metricType": "nonProportion", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_510_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "511", "title": "Percentage of Prevalent Patients Waitlisted for Kidney Transplant (PPPW) and Percentage of Prevalent Patients Waitlisted for Kidney Transplant in Active Status (aPPPW)", "description": "The measure tracks dialysis patients who are under the age of 75 in a practitioner group and on the kidney or kidney-pancreas transplant waitlist (all patients or patients in active status). This measure is a risk-adjusted percentage of waitlist events among dialysis patients.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_511_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "waitlisted", "description": "Percentage of Prevalent Patients Waitlisted (PPPW)." }, { "name": "overall", "description": "Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)." } ] }, { "category": "quality", "measureId": "512", "title": "Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR)", "description": "The number of prevalent dialysis patients in a practitioner group who are under the age of 75 and were listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.", "metricType": "nonProportion", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_512_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M0001", "M0002", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_AKID_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-aki-new-hd.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_CKD_1", "title": "Chronic Kidney Disease (CKD) episode-based cost measure", "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.\nThe CKD episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat stage 4 or 5 chronic kidney disease. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a CKD episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ckd.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_ESRD_1", "title": "End-Stage Renal Disease (ESRD) episode-based cost measure", "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.\nThe ESRD episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage ESRD. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during an ESRD episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-esrd.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_KTM_1", "title": "Kidney Transplant Management episode-based cost measure", "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 D3 are used to construct this episode-based cost measure.\nThe Kidney Transplant Management episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care related to kidney transplant, beginning 90 days post-transplant. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Kidney Transplant Management episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-kidney-tplt.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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"PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure 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"M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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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. 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M0004", "clinicalTopic": "Cognitive-based neurological disorders", "title": "Quality Care for Patients with Neurological Conditions", "description": "The Quality Care for Patients with Neurological Conditions MVP focuses on the clinical theme of promoting quality care for patients suffering from neurological conditions.", "specialtiesMostApplicableTo": [ "Neurology", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Cognitive-based neurological disorders", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "238", "title": "Use of High-Risk Medications in Older Adults", "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS156v14", "eMeasureUuid": "24a5b98e-0bba-44fb-86ff-fcb3f45c0fc4", "nqfEMeasureId": null, "nqfId": "0022", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055", "M0004", "M1421" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "geriatrics", "internalMedicine", "oncology", "ophthalmology", "optometry", "otolaryngology", "pulmonology", "rheumatology", "skilledNursingFacility", "urology" ], "measureSpecification": { 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"initialPopulationUuid": "C3552CAC-11F6-4E4E-89D9-F3999A3B9A3B", "denominatorUuid": "FA269FE8-A1D6-4FC0-9CD2-1AA5E1641CB5", "numeratorUuid": "3751D444-5C47-4D54-BEFE-40BAD4E0EB3F", "denominatorExclusionUuid": "FB873FB8-D7A3-4A72-874F-56852D6312E5" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "CEDAD393-CD57-48F9-979A-C33B9875254C", "denominatorUuid": "A30044E2-4C59-4E0B-A5FD-7553FFA7E851", "numeratorUuid": "14000C16-CD29-44E8-BE5C-D94DED574293", "denominatorExclusionUuid": "154B3202-22A5-4515-B86F-2C7EBB5342DF" }, "name": "totalRate" } ] }, { "category": "quality", "measureId": "268", "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "description": "Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a 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"quality", "measureId": "281", "title": "Dementia: Cognitive Assessment", "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 the 12 months preceding a dementia encounter during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS149v14", "eMeasureUuid": "b8288310-3006-4c9e-a545-b7aa1a3c3eb5", "nqfEMeasureId": "2872e", "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0149v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients for whom an assessment of cognition is performed and the results reviewed at least once within the 12 months preceding a dementia encounter during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "9DEED3EA-9939-4772-9F89-9DC1EE3D2B5F", "denominatorUuid": "D998D635-C003-4EE3-857D-B6061DD4C61C", "numeratorUuid": "036F56EA-99A9-4205-8563-D266D328AD2D", "denominatorExceptionUuid": "CECF1BF8-0831-400A-9266-4540BFED53EF" } } ] }, { "category": "quality", "measureId": "282", "title": "Dementia: Functional Status Assessment", "description": "Percentage of patients with 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"isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_286_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "288", "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "nutritionDietician", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_288_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "291", "title": "Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_291_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "293", "title": "Rehabilitative Therapy Referral for Patients with Parkinson's Disease", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_293_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "386", "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "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 frequently as clinically indicated (i.e., rapid progression).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "speechLanguagePathology" ], "measureSpecification": { "registry": 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felt this provider and team put my best interests first when making recommendations about my care" }, { "name": "seen", "description": "Patient felt this provider and team saw me as a person, not just someone with a medical problem" }, { "name": "understood", "description": "Patient felt this provider and team understood what is important to me in my life" } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "513", "title": "Patient Reported Falls and Plan of Care", "description": "Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_513_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "reporting", "description": "Patients with a diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who were assessed for at each visit during the performance period" }, { "name": "performance", "description": "Patients with a diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who report a fall occurred since the last visit AND who have a plan of care for falls" } ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_24", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "M0001", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_4", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_21", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M0004", "M1423", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_21", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0004", "M1370", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Preventive Care", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "001", "title": "Diabetes: Glycemic Status Assessment Greater Than 9%", "description": "Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS122v14", "eMeasureUuid": "9700a8b9-9f65-41a8-8464-1da26cda857b", "nqfEMeasureId": null, "nqfId": "0059", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "001SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0005", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0122v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_001_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_001_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "51D8CA9A-E511-4793-8AD4-EFAE90F3ABA4", "denominatorUuid": "EA65F958-962E-433B-A9A3-CC2EA7B76E26", "numeratorUuid": "10C65EBE-685C-48F8-8B24-351C6F3481E9", "denominatorExclusionUuid": "CA386077-1F7A-4C23-85D7-33A4FCED0803" } } ] }, { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "236", "title": "Controlling High Blood Pressure", "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS165v14", "eMeasureUuid": "cd9a5c8e-ac16-4e10-a1f4-4dfe48e02cab", "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "236SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0002", "M0005" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0165v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_236_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_236_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "A35D89C5-C903-4D4C-BDBC-EA70D1254BEF", "denominatorUuid": "FECE5EB1-842C-42B6-B2BC-7035C79222E4", "numeratorUuid": "73661F57-1A94-4982-8136-EDCE51A9AEA8", "denominatorExclusionUuid": "8D42520C-8C19-47AF-B3E7-A66EAECA0DBD" } } ] }, { "category": "quality", "measureId": "305", "title": "Initiation and Engagement of Substance Use Disorder Treatment", "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):\r\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. \r\nb. Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS137v14", "eMeasureUuid": "61d66457-70b7-4162-8ad0-07148f505a5e", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0137v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "5546F555-1CBE-4E4E-9FC2-7B8329885844", "denominatorUuid": "1090455E-3666-48A9-B6E1-D426F2305B16", "numeratorUuid": "2F6B7018-D8D5-4805-939D-36718237E09F", "denominatorExclusionUuid": "745EF584-6DC8-4E52-BBD3-0FFD9F9488EC", "strata": [ "B2AE3A04-D7F8-463F-A42C-944B9B487B89", "CAE8F49C-FD7B-4BB5-AAEA-D4388AD86153", "A51DA177-B279-4D54-8267-BCFA529DB924" ] }, "name": "14Days" }, { "description": "Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.", "eMeasureUuids": { "initialPopulationUuid": "101EC2CD-4B29-4B76-9A7C-C4E3C6635977", "denominatorUuid": "B85099F9-F649-47B0-97F3-35CB77B559B4", "numeratorUuid": "A5C6CEA6-D567-4990-9E3C-9091D1689A86", "denominatorExclusionUuid": "93736F21-3C4A-4CAE-9B02-EA9452681AE7", "strata": [ "DAE550C2-BED7-42FB-991C-0EAB5F100576", "DEBA0FD9-0EC4-4D64-A9B1-F9D94548400D", "5B711256-F594-4B26-9587-D75325EDCC22" ] }, "name": "34Days" } ] }, { "category": "quality", "measureId": "321", "title": "CAHPS for MIPs Clinician/Group Survey", "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 CBE 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 CBE)\n• How well Providers Communicate; (Not endorsed by CBE)\n• Patient’s Rating of Provider; (CBE endorsed # 0005)\n• Access to Specialists; (Not endorsed by CBE)\n• Health Promotion and Education; (Not endorsed by CBE)\n• Shared Decision-Making; (Not endorsed by CBE) \n• Health Status and Functional Status; (Not endorsed by CBE)\n• Courteous and Helpful Office Staff; (CBE endorsed # 0005)\n• Care Coordination; (Not endorsed by CBE)\n• Stewardship of Patient Resources. (Not endorsed by CBE)", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M0005", "M1423", "M1503" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {}, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "438", "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS347v9", "eMeasureUuid": "22ea0c5f-5a85-422b-8089-91c24c31bcbb", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M0005", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0347v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_438_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: - All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR - 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; OR - Patients aged 40-75 years with a diagnosis of diabetes; OR - Patients aged 40 to 75 with a 10-year ASCVD risk score of >= 20 percent.", "eMeasureUuids": { "initialPopulationUuid": "DC7EE1FA-285A-447A-AB71-621A180BECBB", "denominatorUuid": "F5A7F615-7471-4549-88FD-C8B447C9685F", "numeratorUuid": "E87BD132-0762-43F1-B61F-427E13BBE7FD", "denominatorExceptionUuid": "5F2E3CBA-C623-492F-8590-A298A5A5240D", "denominatorExclusionUuid": "589CFFC5-DA6E-4A83-822F-97A5025D400B" } } ] }, { "category": "quality", "measureId": "475", "title": "HIV Screening", "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).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": "CMS349v8", "eMeasureUuid": "afc7962b-4e03-4844-9971-ede97d8b6383", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Disease Control and Prevention", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0349v8" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "D9B32E8C-4DAE-4FE1-A876-068600695912", "denominatorUuid": "5A9314BA-D97B-465B-8B85-A45FD3F9ABE2", "numeratorUuid": "F5430ED0-63AB-4E8B-AD99-3DE79F592129", "denominatorExceptionUuid": "2841A0A9-75E9-4F09-884A-47173061F2C2", "denominatorExclusionUuid": "5A6EBD39-0BA6-4AC4-87AB-94A0132AF7BC" } } ] }, { "category": "quality", "measureId": "483", "title": "Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)", "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.", "metricType": "nonProportion", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3568", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "The American Board of Family Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_483_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "493", "title": "Adult Immunization Status", "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; pneumococcal; and hepatitis B.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_493_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" }, "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 2 doses of the herpes zoster recombinant vaccine anytime on October 20, 2017, through the end of the measurement period." }, { "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 19th birthday and before the end of the measurement period." }, { "name": "hepB", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who were administered a hepatitis B vaccine series." } ] }, { "category": "quality", "measureId": "497", "title": "Preventive Care and Wellness (composite)", "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).", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_497_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 65 years of age or older who received a pneumococcal vaccination on or after their 19th 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 Body Mass Index (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" } ] }, { "category": "quality", "measureId": "504", "title": "Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk", "description": "Percentage of patients aged 12 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_504_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_22", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_23", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005", "M1366" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_25", "title": "Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk", "description": "Implement standardized, evidence-based cardiovascular disease risk assessment and care management for a defined population in the clinician’s practice.\nThe clinician or clinician group will apply standardized risk assessment and care management to a broad, clinician-defined patient population in the practice. The population can be defined by 1) patient age and/or atherosclerotic cardiovascular disease (ASCVD) risk factors; or 2) the constraints of the risk assessment tool (for example, the American College of Cardiology (ACC)/American Heart Association (AHA) ASCVD Risk Calculator is validated for patients over age 40).\nThe results of screening and the plan for treatment and follow up will be documented using a standardized method in the patient’s medical record. Care management plan and follow up intervals will be influenced by the degree of patient risk.\nCardiovascular care management should be defined by risk assessment and lead to the development of individualized care plans with specific goals. Shared decision making should be part of the development of every patient care plan.", "metricType": "boolean", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_ACOPD_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-chron-copd.pdf" }, "allowedPrograms": [ "mips", "M0005", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_D_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-diabetes.pdf" }, "allowedPrograms": [ "mips", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_DEP_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-depression.pdf" }, "allowedPrograms": [ "mips", "M0005", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_HF_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-heart-fail.pdf" }, "allowedPrograms": [ "mips", "G0055", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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": [ { "category": "quality", "measureId": "039", "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "description": "Percentage of women aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) test to check for osteoporosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M1366" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_039_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_039_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "048", "title": "Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_048_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "112", "title": "Breast Cancer Screening", "description": "Percentage of women 40 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS125v14", "eMeasureUuid": "dbd9eccd-c3ea-42db-9344-72ad44f84f51", "nqfEMeasureId": null, "nqfId": "2372", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "112SSP" ], "allowedPrograms": [ "appPlus", "M1366" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0125v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_112_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_112_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period", "eMeasureUuids": { "initialPopulationUuid": "87CE9EB7-380D-42EF-848A-DDE91AB59EAD", "denominatorUuid": "9D4334D0-F035-4B79-AE94-CE33E1CCFA66", "numeratorUuid": "B8A1855E-325E-4C1F-A69A-1CD4F2453054", "denominatorExclusionUuid": "3EB42551-4D50-4437-BDD5-75CE69DB29AA", "strata": [ "71e018e5-edfd-47f2-aa52-fce7cf916904", "19463c73-e334-481d-88bd-6b7ba8895337" ] } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "309", "title": "Cervical Cancer Screening", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed within the last 3 years* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS124v14", "eMeasureUuid": "e3e538bf-197a-4b4e-89c7-cc40c550a45f", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0124v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria: - Cervical cytology performed during the measurement period or the two years prior to the measurement period for women 24-64 years of age by the end of the measurement period. - Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test.", "eMeasureUuids": { "initialPopulationUuid": "E85A469F-8A90-43B2-8E94-C2AF73A6FA5D", "denominatorUuid": "3B6E90F0-0361-451E-B472-971601A70D4A", "numeratorUuid": "6A236D90-E202-42EE-8AA6-0743B659F06A", "denominatorExclusionUuid": "C9602136-DBDF-43FD-975E-D7153704C947" } } ] }, { "category": "quality", "measureId": "310", "title": "Chlamydia Screening in Women", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS153v14", "eMeasureUuid": "59738aab-1f1a-4097-82c1-cd7bf3714afa", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0153v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "938888B6-FF4F-4431-A464-52E770E6D9ED", "denominatorUuid": "7B198078-DCA5-4E4D-A9DE-5C37D68EABF5", "numeratorUuid": "088B388C-E545-4450-A24F-0A027A58E952", "denominatorExclusionUuid": "0D49F098-5B25-4D08-BA45-8360F3641559", "strata": [ "f71d06b9-1df1-404e-a65f-dfd3227548d8", "a6120934-b093-4c8a-b358-3428bd846fd2" ] } } ] }, { "category": "quality", "measureId": "335", "title": "Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_335_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "336", "title": "Maternity Care: Postpartum Follow-up and Care Coordination", "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: breastfeeding evaluation and education, postpartum depression screening, intimate partner violence 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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_336_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "400", "title": "One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation", "description": "Percentage of patients age ≥ 18 years who 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_400_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "screening", "description": "Percentage of patients aged ≥ 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 aged ≥ 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." } ] }, { "category": "quality", "measureId": "422", "title": "Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury", "description": "Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2063", "measureType": "process", "isHighPriority": true, "primarySteward": "American Urogynecologic Society", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_422_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_422_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "431", "title": "Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling", "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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2152", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "obstetricsGynecology", "oncology", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "urgentCare", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_431_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "reporting", "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." }, { "name": "performance", "description": "Percentage of patients aged 18 years and older who were identified as unhealthy alcohol users who received brief counseling." }, { "name": "combinedPopulations", "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 unhealthy alcohol users." } ] }, { "category": "quality", "measureId": "432", "title": "Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair", "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bladder or bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urogynecologic Society", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_432_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "bladderInjury", "description": "Percentage of patients undergoing prolapse repair who sustain a bladder injury that necessitates repair either intraoperatively or within 30 days after surgery ." }, { "name": "bowelInjury", "description": "Percentage of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after surgery." } ] }, { "category": "quality", "measureId": "448", "title": "Appropriate Workup Prior to Endometrial Ablation", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_448_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "475", "title": "HIV Screening", "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).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": "CMS349v8", "eMeasureUuid": "afc7962b-4e03-4844-9971-ede97d8b6383", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Disease Control and Prevention", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0349v8" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "D9B32E8C-4DAE-4FE1-A876-068600695912", "denominatorUuid": "5A9314BA-D97B-465B-8B85-A45FD3F9ABE2", "numeratorUuid": "F5430ED0-63AB-4E8B-AD99-3DE79F592129", "denominatorExceptionUuid": "2841A0A9-75E9-4F09-884A-47173061F2C2", "denominatorExclusionUuid": "5A6EBD39-0BA6-4AC4-87AB-94A0132AF7BC" } } ] }, { "category": "quality", "measureId": "493", "title": "Adult Immunization Status", "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; pneumococcal; and hepatitis B.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_493_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" }, "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 2 doses of the herpes zoster recombinant vaccine anytime on October 20, 2017, through the end of the measurement period." }, { "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 19th birthday and before the end of the measurement period." }, { "name": "hepB", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who were administered a hepatitis B vaccine series." } ] }, { "category": "quality", "measureId": "496", "title": "Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument", "description": "Percentage of pregnant or postpartum patients who received a cardiovascular disease (CVD) risk assessment with a standardized instrument.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "University of California, Irvine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_496_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1649514" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_23", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005", "M1366" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", 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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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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"M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Audiologists", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Otolaryngology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "128", "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if BMI was outside of normal parameters.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS69v14", "eMeasureUuid": "6eabf62a-209b-4969-829e-04c502db761d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "G0055", "G0058", "M1367", "M1370", "M1424" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0069v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_128_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_128_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5A321168-A454-4BD9-B82E-A403B009DE8F", "denominatorUuid": "7980B172-09ED-4A0C-B29C-D652DB845BF5", "numeratorUuid": "5AF09C9B-07A3-4BF4-A366-7AEA9C934050", "denominatorExceptionUuid": "5509373E-4ACA-4B71-8E56-E42BBB1A3880", "denominatorExclusionUuid": "50128A04-F2DD-4B6D-A078-B16904431CEC" } } ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "277", "title": "Sleep Apnea: Severity Assessment at Initial Diagnosis", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Sleep Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "otolaryngology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_277_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "331", "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_331_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "332", "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_332_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "355", "title": "Unplanned Reoperation within the 30-Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30-day postoperative period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_355_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "357", "title": "Surgical Site Infection (SSI)", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_357_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "AAO16", "title": "Age-Related Hearing Loss: Comprehensive Audiometric Evaluation", "description": "Percentage of patients aged 50 years and older who failed a hearing screening and/or who report suspected hearing loss who received, were ordered, or were referred for comprehensive audiometric evaluation within 4 weeks of the office visit", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO20", "title": "Tympanostomy Tubes: Comprehensive Audiometric Evaluation", "description": "Percentage of patients aged 6 months through 12 years with a diagnosis of otitis media with effusion (OME) who received tympanostomy tube insertion and received a comprehensive audiometric evaluation within 6 months prior to tympanostomy tube insertion", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO21", "title": "Otitis Media with Effusion (OME): Comprehensive Audiometric Evaluation for Chronic OME > or = 3 months", "description": "Percentage of patients aged 6 months to 12 years of age with a diagnosis of otitis media with effusion (OME) including chronic serous, mucoid, or nonsuppurative OME of > or = 3 months duration who had or received an order or referral for comprehensive audiometric evaluation", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Infectious Disease, Immunology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "065", "title": "Appropriate Treatment for Upper Respiratory Infection (URI)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS154v14", "eMeasureUuid": "22233707-222d-473d-9acb-8ef6cedd0690", "nqfEMeasureId": null, "nqfId": "0069", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "infectiousDisease", "pediatrics", "urgentCare" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0154v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_065_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection", "eMeasureUuids": { "initialPopulationUuid": "50D6E6FD-F841-4E7C-9719-CD484A43AC8A", "denominatorUuid": "5DB707B9-4D8B-4CAF-B8AB-4310B02681D0", "numeratorUuid": "824D23C2-A5B6-472D-BF80-C01FDCE067B5", "denominatorExclusionUuid": "932D4556-8347-4562-9B3A-179FD75D7317", "strata": [ "ecc38660-2537-4dbf-9432-cb8d21bed027", "5040441a-d27d-451b-b610-888525d40317", "a65aac60-e26a-4e79-a358-eead473ed112" ] } } ] }, { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "205", "title": "Sexually Transmitted Infection (STI) Testing for People with HIV", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS1188v3", "eMeasureUuid": "d8167543-0d18-4832-b87a-9d5f1c227215", "nqfEMeasureId": "3755e", "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Health Resources and Services Administration", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "infectiousDisease", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1188v3", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_205_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were tested for each of the following at least once during the measurement period: chlamydia, gonorrhea, and syphilis", "eMeasureUuids": { "initialPopulationUuid": "E9614413-6EAC-4C48-A69D-A9DC1A228954", "denominatorUuid": "69732BC0-17DD-40BA-995C-689E8FDB7838", "numeratorUuid": "604D6C9E-C89B-4F4A-A3CB-E14B100E02F3" } } ] }, { "category": "quality", "measureId": "240", "title": "Childhood Immunization Status", "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 (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS117v14", "eMeasureUuid": "65c8fea2-95e8-434e-8fd0-9450717430d9", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "infectiousDisease", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0117v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "DTaP Children with any of the following on or before the child’s second birthday meet criteria: - At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine. - Encephalitis due to the diphtheria, tetanus or pertussis vaccine. IPV Children with either of the following on or before the child’s second birthday meet criteria: - At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the IPV vaccine. MMR Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. - All of the following anytime on or before the child’s second birthday (on the same or different date of service): - History of measles. - History of mumps. - History of rubella. HiB Children with either of the following meet criteria on or before the child’s second birthday: - At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the HiB vaccine. HepB Children with any of the following on or before the child’s second birthday meet criteria: - At least three hepatitis B vaccinations, with different dates of service. - 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. - Anaphylaxis due to the hepatitis B vaccine. - History of hepatitis B illness. VZV Children with any of the following meet criteria: - At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays. - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday. - History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. PCV Children with either of the following on or before the child’s second birthday meet criteria: - 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. - Anaphylaxis due to the pneumococcal vaccine. HepA Children with any of the following meet criteria: - At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays. - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. - History of hepatitis A illness on or before the child’s second birthday. RV Children with any of the following meet criteria: - 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. - 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. - 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. - Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday. Flu Children with either of the following on or before their second birthday meet criteria: - 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. - 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. - Anaphylaxis due to the influenza vaccine.", "eMeasureUuids": { "initialPopulationUuid": "09CA0EF6-9AE4-4636-A2BF-CAC945A03AF5", "denominatorUuid": "4B91AD4E-0169-4694-843C-89035AF1F85C", "numeratorUuid": "667F8CB8-6C2B-403B-9C04-DF21FB800310", "denominatorExclusionUuid": "A37C5F96-E949-4191-806E-2808BBD2F2BA" } } ] }, { "category": "quality", "measureId": "310", "title": "Chlamydia Screening in Women", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS153v14", "eMeasureUuid": "59738aab-1f1a-4097-82c1-cd7bf3714afa", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0153v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "938888B6-FF4F-4431-A464-52E770E6D9ED", "denominatorUuid": "7B198078-DCA5-4E4D-A9DE-5C37D68EABF5", "numeratorUuid": "088B388C-E545-4450-A24F-0A027A58E952", "denominatorExclusionUuid": "0D49F098-5B25-4D08-BA45-8360F3641559", "strata": [ "f71d06b9-1df1-404e-a65f-dfd3227548d8", "a6120934-b093-4c8a-b358-3428bd846fd2" ] } } ] }, { "category": "quality", "measureId": "338", "title": "HIV Viral Suppression", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS314v3", "eMeasureUuid": "8ea82ad9-51bf-494c-ad91-2b14e8717bc7", "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0314v3", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_338_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a last HIV viral load test result of less than 200 copies/mL during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "3528D887-61BE-4C3C-B7D9-5F47174AEBFF", "denominatorUuid": "D8FB20C1-A50F-4028-AC7F-4DADFE67C998", "numeratorUuid": "6AEBD0C9-6E38-4353-A6BB-DB44FBC6DC87" } } ] }, { "category": "quality", "measureId": "340", "title": "HIV Annual Retention in Care", "description": "Percentage of patients, regardless of age, with a diagnosis of Human Immunodeficiency Virus (HIV) before or during the first 240 days of the performance period who had at least two eligible encounters or at least one eligible encounter and one HIV viral load test that were at least 90 days apart within the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS1157v2", "eMeasureUuid": "6685abfc-63d7-4bcf-a293-ecbfa2c8edf1", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "infectiousDisease" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1157v2", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_340_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients who had at least one eligible encounter and one HIV viral load test at least 90 days apart during the measurement period, or who had at least two eligible encounters at least 90 days apart during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "CC41EFF0-6053-49C9-8E9F-1536548B147B", "denominatorUuid": "2F0FF94A-A7A7-4DE9-9776-C55A939B6DDF", "numeratorUuid": "13D2124C-C80D-4B32-A76A-8E5BD50DD974" } } ] }, { "category": "quality", "measureId": "387", "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_387_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "400", "title": "One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation", "description": "Percentage of patients age ≥ 18 years who 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_400_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "screening", "description": "Percentage of patients aged ≥ 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 aged ≥ 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." } ] }, { "category": "quality", "measureId": "401", "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_401_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "475", "title": "HIV Screening", "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).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": "CMS349v8", "eMeasureUuid": "afc7962b-4e03-4844-9971-ede97d8b6383", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Disease Control and Prevention", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0349v8" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "D9B32E8C-4DAE-4FE1-A876-068600695912", "denominatorUuid": "5A9314BA-D97B-465B-8B85-A45FD3F9ABE2", "numeratorUuid": "F5430ED0-63AB-4E8B-AD99-3DE79F592129", "denominatorExceptionUuid": "2841A0A9-75E9-4F09-884A-47173061F2C2", "denominatorExclusionUuid": "5A6EBD39-0BA6-4AC4-87AB-94A0132AF7BC" } } ] }, { "category": "quality", "measureId": "493", "title": "Adult Immunization Status", "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; pneumococcal; and hepatitis B.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_493_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" }, "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 2 doses of the herpes zoster recombinant vaccine anytime on October 20, 2017, through the end of the measurement period." }, { "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 19th birthday and before the end of the measurement period." }, { "name": "hepB", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who were administered a hepatitis B vaccine series." } ] }, { "category": "quality", "measureId": "516", "title": "Hepatitis C Virus (HCV): Sustained Virological Response (SVR)", "description": "Percentage of patients aged greater than or equal to 18 years with active hepatitis C (HCV) with negative/undetectable HCV ribonucleic acid (RNA) at least 20 weeks to 12 months after positive/detectable HCV RNA test result.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_516_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "M0001", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_22", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_23", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_32", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1368", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_RIH_1", "title": "Respiratory Infection Hospitalization episode-based cost measure", "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.\nThe Respiratory Infection Hospitalization episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive inpatient treatment for a respiratory infection 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.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-resp-infxn.pdf" }, "allowedPrograms": [ "mips", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_S_1", "title": "Sepsis", "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, B, and D are used to construct the episode-based cost measures. The Sepsis episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive inpatient medical treatment for sepsis 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 45 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-sepsis.pdf" }, "allowedPrograms": [ "mips", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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", "Nonphysician Practitioners", "Clinical Social Workers", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Mental Health, Behavioral Health, Psychiatry", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "009", "title": "Antidepressant Medication Management", "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).", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS128v14", "eMeasureUuid": "ee910ec9-e9e4-4fd2-8f04-68b2cf545719", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0128v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).", "eMeasureUuids": { "initialPopulationUuid": "FB7963B0-4087-4620-831A-011F11461F1D", "denominatorUuid": "6377FF0F-DF03-46C5-9269-4047935DEF0D", "numeratorUuid": "2F9BA0BC-A3A0-4F25-AF9E-FD3BB4DEA05A", "denominatorExclusionUuid": "CEE186A0-C49C-48C1-B6A2-9D3DBDCAB754" }, "name": "84Days" }, { "description": "Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "eMeasureUuids": { "initialPopulationUuid": "6E7B2368-CCCA-4414-856A-4BC93DCF2067", "denominatorUuid": "E05BAE38-1702-461A-8FF8-50E41D18483B", "numeratorUuid": "2D4DFEFA-9E20-46FC-BAFB-2685D0DADC70", "denominatorExclusionUuid": "CC153620-82CB-4D5B-9262-9958EC3DBAD2" }, "name": "180Days" } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "305", "title": "Initiation and Engagement of Substance Use Disorder Treatment", "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):\r\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. \r\nb. Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS137v14", "eMeasureUuid": "61d66457-70b7-4162-8ad0-07148f505a5e", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0137v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "5546F555-1CBE-4E4E-9FC2-7B8329885844", "denominatorUuid": "1090455E-3666-48A9-B6E1-D426F2305B16", "numeratorUuid": "2F6B7018-D8D5-4805-939D-36718237E09F", "denominatorExclusionUuid": "745EF584-6DC8-4E52-BBD3-0FFD9F9488EC", "strata": [ "B2AE3A04-D7F8-463F-A42C-944B9B487B89", "CAE8F49C-FD7B-4BB5-AAEA-D4388AD86153", "A51DA177-B279-4D54-8267-BCFA529DB924" ] }, "name": "14Days" }, { "description": "Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.", "eMeasureUuids": { "initialPopulationUuid": "101EC2CD-4B29-4B76-9A7C-C4E3C6635977", "denominatorUuid": "B85099F9-F649-47B0-97F3-35CB77B559B4", "numeratorUuid": "A5C6CEA6-D567-4990-9E3C-9091D1689A86", "denominatorExclusionUuid": "93736F21-3C4A-4CAE-9B02-EA9452681AE7", "strata": [ "DAE550C2-BED7-42FB-991C-0EAB5F100576", "DEBA0FD9-0EC4-4D64-A9B1-F9D94548400D", "5B711256-F594-4B26-9587-D75325EDCC22" ] }, "name": "34Days" } ] }, { "category": "quality", "measureId": "366", "title": "Follow-Up Care for Children Prescribed ADHD Medication", "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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS136v15", "eMeasureUuid": "511a583c-a282-448d-9415-2a4c6ee166b6", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0136v15" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "B88DD062-C0C1-46D4-A739-C607A37BB261", "denominatorUuid": "0EBDF7B3-3C2A-4221-8FC6-5CC442975352", "numeratorUuid": "8AC76953-1D7C-4729-8F96-3AFC552A99EB", "denominatorExclusionUuid": "02DD44D5-0DB1-4DC2-81CF-B2A71663280E" }, "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": "B36D1E39-517E-48A2-866F-F4A1C7D12726", "denominatorUuid": "6DC20C09-1A43-4632-8CEB-A3A5FA191E64", "numeratorUuid": "53EB472F-C673-4572-99FF-21AE87C9169B", "denominatorExclusionUuid": "E90337E4-28CC-49DE-9FC6-1139B386F21A" }, "name": "overall" } ] }, { "category": "quality", "measureId": "370", "title": "Depression Remission at Twelve Months", "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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS159v14", "eMeasureUuid": "f76d9f75-58fc-42f4-b97a-2491339dd571", "nqfEMeasureId": "0710e", "nqfId": "0710", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0159v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_370_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "B74991E6-6F3A-4A01-A60A-6FEEFC966414", "denominatorUuid": "55D888FB-ADA0-4D51-858F-4E942F0F670E", "numeratorUuid": "BF66AA4C-0510-43F8-BF08-A95A71A1E50E", "denominatorExclusionUuid": "21908786-DDBF-4121-A704-D2E237A676BB", "strata": [ "C4A59042-1634-4A8B-812F-BE0A4450D0D2", "A3418DB5-F6AE-47A4-9F77-EA8B7EA583C9" ] }, "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" } ] }, { "category": "quality", "measureId": "382", "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS177v14", "eMeasureUuid": "59498f05-2fed-4cb3-b12c-aa70a0955d91", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Mathematica", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0177v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "7C14B90C-F2F0-48E1-BBCF-00A448D7E473", "denominatorUuid": "970D4B91-57A3-4B37-AB74-5F4A82B5D359", "numeratorUuid": "9FD89923-0BA7-45E2-BC9A-A23AD05BB625" } } ] }, { "category": "quality", "measureId": "383", "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_383_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "468", "title": "Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "University of Southern California", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "physicalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_468_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "502", "title": "Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder", "description": "The percentage of patients 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 Scale (SDS) 30 to 180 days after an index assessment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_502_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "504", "title": "Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk", "description": "Percentage of patients aged 12 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_504_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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." } ] }, { "category": "quality", "measureId": "505", "title": "Reduction in Suicidal Ideation or Behavior Symptoms", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_505_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] }, { "category": "quality", "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.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_23", "title": "Integration of patient coaching practices between visits", "description": "Provide coaching between visits with follow-up on care plan and goals.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M1369", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0059", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_5", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_32", "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1368", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_DEP_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-depression.pdf" }, "allowedPrograms": [ "mips", "M0005", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_PRC_1", "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).", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-psych.pdf" }, "allowedPrograms": [ "mips", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1370", "clinicalTopic": "Rehabilitative support for musculoskeletal care.", "title": "Rehabilitative Support for Musculoskeletal Care", "description": "The Rehabilitative Support for Musculoskeletal Care MVP focuses on the clinical theme of promoting quality care for patients.", "specialtiesMostApplicableTo": [ "Chiropractic Medicine", "Physiatry", "Physical Therapy", "Occupational Therapy", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Rehabilitative support for musculoskeletal care.", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "050", "title": "Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "physicalTherapyOccupationalTherapy", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_050_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "128", "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if BMI was outside of normal parameters.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS69v14", "eMeasureUuid": "6eabf62a-209b-4969-829e-04c502db761d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "G0055", "G0058", "M1367", "M1370", "M1424" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0069v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_128_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_128_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5A321168-A454-4BD9-B82E-A403B009DE8F", "denominatorUuid": "7980B172-09ED-4A0C-B29C-D652DB845BF5", "numeratorUuid": "5AF09C9B-07A3-4BF4-A366-7AEA9C934050", "denominatorExceptionUuid": "5509373E-4ACA-4B71-8E56-E42BBB1A3880", "denominatorExclusionUuid": "50128A04-F2DD-4B6D-A078-B16904431CEC" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "155", "title": "Falls: Plan of Care", "description": "Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0101", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "familyMedicine", "geriatrics", "internalMedicine", "neurology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_155_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "182", "title": "Functional Outcome Assessment", "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies within two days of the date of the identified deficiencies.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "chiropracticMedicine", "familyMedicine", "nephrology", "orthopedicSurgery", "physicalMedicine", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_182_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "217", "title": "Functional Status Change for Patients with Knee Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with knee impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) 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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_217_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "218", "title": "Functional Status Change for Patients with Hip Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with hip impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) 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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_218_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "219", "title": "Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with foot, ankle or lower leg impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) 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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "podiatry" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_219_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "220", "title": "Functional Status Change for Patients with Low Back Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with low back impairments. The change in FS is assessed using the FOTO Low Back 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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_220_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "221", "title": "Functional Status Change for Patients with Shoulder Impairments", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_221_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "222", "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_222_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "478", "title": "Functional Status Change for Patients with Neck Impairments", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3461", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_478_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "MSK6", "title": "Patients Suffering From a Neck Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a neck injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK7", "title": "Patients Suffering From an Upper Extremity Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from an upper extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK8", "title": "Patients Suffering From a Back Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a back injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK9", "title": "Patients Suffering From a Lower Extremity Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a lower extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M1369", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_8", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_3", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_8", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1421", "M1422", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M0001", "M0002", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_21", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0004", "M1370", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_LBP_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-low-back.pdf" }, "allowedPrograms": [ "mips", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", 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"isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_384_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "385", "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_385_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "389", "title": "Cataract Surgery: Difference Between Planned and Final Refraction", "description": "Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_389_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "499", "title": "Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy", "description": "Percentage of patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) who, within seven (7) weeks following the date of injection, are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP =<25 mm Hg for injected eye OR if the IOP was >25 mm Hg, a plan of care was documented.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Retina Specialists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_499_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "500", "title": "Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up", "description": "Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 8 weeks.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Retina Specialists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_500_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" } }, { "category": "quality", "measureId": "501", "title": "Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up", "description": "Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) and acute vitreous hemorrhage in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 2 weeks.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Retina Specialists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_501_MIPSCQM .pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" } }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "IRIS13", "title": "Diabetic Macular Edema - Loss of Visual Acuity", "description": "Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) within the past 12 months.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS2", "title": "Glaucoma – Intraocular Pressure Reduction", "description": "Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS39", "title": "Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure", "description": "Percentage of patients who underwent trabeculectomy or aqueous shunt procedure who had IOP reduced by 20% or more from their pretreatment between 3 and 4 months of treatment or a reduction in overall number of glaucoma medications.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS54", "title": "Complications After Cataract Surgery", "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had the following complications with 90 days after cataract surgery: prolonged inflammation, incision complications, iris complications, retinal detachment, cystoid macular edema, corneal complications, or a return to OR.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS58", "title": "Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days", "description": "Percentage of patients with a 20% or greater improvement in visual acuity within 120 days following vitrectomy for complications of diabetic retinopathy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS61", "title": "Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery", "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and minimally invasive glaucoma surgery and achieved 20/30 best-corrected distance visual acuity or better within 4 months following the cataract surgery.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_25", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M1420" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_10", "title": "Care transition documentation practice improvements", "description": "In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1420", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_IOL_1", "title": "Cataract Removal with Intraocular Lens (IOL) Implantation episode-based cost measure", "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.\nThe Cataract Removal with IOL Implantation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a procedure for cataract removal with IOL implantation 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 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-cataract1.pdf" }, "allowedPrograms": [ "mips", "M1420" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1421", "clinicalTopic": "Dermatology Care", "title": "Dermatological Care", "description": "The Dermatological Care MVP focuses on the clinical theme of providing treatment and management of dermatologic care.", "specialtiesMostApplicableTo": [ "Dermatology", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Dermatology Care", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "176", "title": "Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "infectiousDisease", "internalMedicine", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_176_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "238", "title": "Use of High-Risk Medications in Older Adults", "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS156v14", "eMeasureUuid": "24a5b98e-0bba-44fb-86ff-fcb3f45c0fc4", "nqfEMeasureId": null, "nqfId": "0022", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055", "M0004", "M1421" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "geriatrics", "internalMedicine", "oncology", "ophthalmology", "optometry", "otolaryngology", "pulmonology", "rheumatology", "skilledNursingFacility", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0156v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_238_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F8EF7E4A-80B9-4A74-8461-498D79DA5442", "denominatorUuid": "D1555193-7364-45F6-94A6-F1DC2E78C197", "numeratorUuid": "466F79E9-53CB-427E-AB56-2ACFA1969921", "denominatorExclusionUuid": "A8A6B357-128E-4A03-B7E7-D1BFAB85700B" }, "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": "C3552CAC-11F6-4E4E-89D9-F3999A3B9A3B", "denominatorUuid": "FA269FE8-A1D6-4FC0-9CD2-1AA5E1641CB5", "numeratorUuid": "3751D444-5C47-4D54-BEFE-40BAD4E0EB3F", "denominatorExclusionUuid": "FB873FB8-D7A3-4A72-874F-56852D6312E5" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "CEDAD393-CD57-48F9-979A-C33B9875254C", "denominatorUuid": "A30044E2-4C59-4E0B-A5FD-7553FFA7E851", "numeratorUuid": "14000C16-CD29-44E8-BE5C-D94DED574293", "denominatorExclusionUuid": "154B3202-22A5-4515-B86F-2C7EBB5342DF" }, "name": "totalRate" } ] }, { "category": "quality", "measureId": "397", "title": "Melanoma Reporting", "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_397_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_397_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "410", "title": "Psoriasis: Clinical Response to Systemic Medications", "description": "Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_410_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "440", "title": "Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician", "description": "Percentage of biopsies with a diagnosis of cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_440_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "485", "title": "Psoriasis - Improvement in Patient-Reported Itch Severity", "description": "The percentage of patients, aged 8 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 3 or more points at a follow up visit.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_485_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "486", "title": "Dermatitis – Improvement in Patient-Reported Itch Severity", "description": "The percentage of patients, aged 8 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 3 or more points at a follow up visit.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_486_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "509", "title": "Melanoma: Tracking and Evaluation of Recurrence", "description": "Percentage of patients who had an excisional surgery for melanoma or melanoma in situ with initial American Joint Committee on Cancer (AJCC) staging of 0, I, or II, in the past 5 years in which the operating provider examines and/or diagnoses the patient for recurrence of melanoma.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_509_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "overall", "description": "Documentation by the clinician who performed the surgery that an exam for recurrence of melanoma was performed on the patient within the performance period" }, { "name": "incidence", "description": "All patients that were diagnosed with a recurrent melanoma in the current performance period" } ] }, { "category": "quality", "measureId": "AAD12", "title": "Melanoma: – Appropriate Surgical Margins", "description": "Percentage of primary excisional surgeries for melanoma or melanoma in situ with Breslow depth and appropriate surgical margins per the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology- Melanoma (NCCN Guideline).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD16", "title": "Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures", "description": "Percentage of procedures in patients aged 18 and older with a diagnosis of skin cancer who underwent intermediate layer or complex linear closure or reconstruction after skin cancer resection in the office-based* setting who were prescribed post-operative systemic antibiotics to be taken immediately following reconstruction surgery (inverse measure).\n\nThis measure is stratified by intermediate layer or complex linear closure or reconstructive procedures.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ], "strata": [ { "name": "resection", "description": "Strata 1: Intermediate layer or complex linear closures after skin cancer resection" }, { "name": "reconstruction", "description": "Strata 2: Reconstruction after skin cancer resection " }, { "name": "overall", "description": "Strata 3: FOR REPORTING\r\nStrata 1 + Strata 2; Calculate as (numerator 1 + numerator 2 )/(denominator 1 + denominator 2), not the average of the performance rates" } ] }, { "category": "quality", "measureId": "AAD6", "title": "Skin Cancer: Biopsy Reporting Time - Clinician to Patient", "description": "Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma or melanoma (including in situ disease) or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 8 days from the time the biopsy was performed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD8", "title": "Chronic Skin Conditions: Patient Reported Quality-of-Life", "description": "The percentage of patients aged 18 years and older with a chronic skin condition whose self-assessed quality-of-life was recorded at least once in the medical record within the measurement period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_8", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1421", "M1422", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_8", "title": "Use of Patient Safety Tools", "description": "In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1421", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_MR_1", "title": "Melanoma Resection", "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 Melanoma Resection episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo an excision procedure to remove a cutaneous melanoma 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.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-mel-rsct.pdf" }, "allowedPrograms": [ "mips", "M1421" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1422", "clinicalTopic": "Gastroenterology Care", "title": "Gastroenterology Care", "description": "The Gastroenterology Care MVP focuses on the clinical theme of providing treatment and management of the digestive system and the liver.", "specialtiesMostApplicableTo": [ "Gastroenterology", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Gastroenterology Care", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "113", "title": "Colorectal Cancer Screening", "description": "Percentage of patients 45-75 years of age who had appropriate screening for colorectal cancer.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS130v14", "eMeasureUuid": "5f4ca523-517d-4872-ba8d-63a29e337d85", "nqfEMeasureId": null, "nqfId": "0034", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "113SSP" ], "allowedPrograms": [ "appPlus", "M1422" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0130v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_113_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_113_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: - Fecal occult blood test (FOBT) during the measurement period - Stool DNA (sDNA) with FIT test during the measurement period or the two years prior to the measurement period - Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period - CT Colonography during the measurement period or the four years prior to the measurement period - Colonoscopy during the measurement period or the nine years prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "F551C910-F688-450C-9C76-88401EDA98FA", "denominatorUuid": "5B1B895A-CD14-4AE2-9461-D599B5D73D31", "numeratorUuid": "1C4A619B-74C1-4C1F-A6C8-3178C7E595AA", "denominatorExclusionUuid": "7AEB935C-8F1E-47B3-97AE-CEB97C06E4E6", "strata": [ "7e4ffd7d-9488-4056-a84f-494767668e09", "24170b02-9435-4a38-bb47-d5837475d0db" ] } } ] }, { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", 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years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 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"metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_275_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "320", "title": "Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients", "description": "Percentage of patients aged 45 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of 10 years for repeat colonoscopy documented in their colonoscopy report.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0658", "measureType": "process", "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_320_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_320_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "374", "title": "Closing the Referral Loop: Receipt of Specialist Report", "description": "Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS50v14", "eMeasureUuid": "2af15f05-07a9-4f5c-9a40-11ea768adcda", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420", "M1422", "M1499", "M1502", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "internalMedicine", "interventionalRadiology", "neurology", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0050v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_374_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients with a referral on or before October 31, for which the referring clinician received a report from the first clinician to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "D36BF246-D75C-41C1-B4F6-FA174EC27C0D", "denominatorUuid": "894E9268-7EE5-4E26-BF65-4256C215414D", "numeratorUuid": "B5A8F06A-68CE-428F-8FBA-FCCEE730ED0C" } } ] }, { "category": "quality", "measureId": "400", "title": "One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation", "description": "Percentage of patients age ≥ 18 years who 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_400_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "screening", "description": "Percentage of patients aged ≥ 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 aged ≥ 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." } ] }, { "category": "quality", "measureId": "401", "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_401_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "516", "title": "Hepatitis C Virus (HCV): Sustained Virological Response (SVR)", "description": "Percentage of patients aged greater than or equal to 18 years with active hepatitis C (HCV) with negative/undetectable HCV ribonucleic acid (RNA) at least 20 weeks to 12 months after positive/detectable HCV RNA test result.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_516_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "GIQIC23", "title": "Appropriate follow-up interval based on pathology findings in screening colonoscopy", "description": "Percentage of procedures among average-risk patients aged 45 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "GIQuIC in Collaboration with American College of Gastroenterology, American Society for Gastrointestinal Endoscopy", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5846856" ], "strata": [ { "name": "overall", "description": "Overall percentage of procedures among average-risk patients aged 45 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report" }, { "name": "hyperPolyps&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of only hyperplastic polyps for which a recommended follow-up interval of 10 years for repeat colonoscopy was given to the patient" }, { "name": "1-2adenoma&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of 1-2 tubular adenoma(s) for which a recommended follow-up interval of not less than 7 years and not greater than 10 years was given to the patient" }, { "name": "3-4adenomas&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of 3-4 tubular adenomas for which a recommended follow-up interval of not less than 3 years and not greater than 5 years was given to the patient" }, { "name": "5-10adenoma&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of 5-10 tubular adenomas for which a recommended follow-up interval of 3 years was given to the patient" }, { "name": "neoplasm&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of Advanced Neoplasm (>= 10 mm, high grade dysplasia, villous component) for which a recommended follow-up interval of 3 years for repeat colonoscopy was given to the patient" }, { "name": "serration&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of Sessile serrated polyp >= 10 mm OR sessile serrated polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy consistent was given to the patient" } ] }, { "category": "quality", "measureId": "GIQIC26", "title": "Screening Colonoscopy Adenoma Detection Rate", "description": "The percentage of patients aged 45 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "GIQuIC in Collaboration with American College of Gastroenterology, American Society for Gastrointestinal Endoscopy", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5846856" ], "strata": [ { "name": "overall", "description": "Simple average of Rate 2 and Rate 3" }, { "name": "male", "description": "The percentage of male patients aged 45 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy" }, { "name": "female", "description": "The percentage of female patients aged 45 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy" } ] }, { "category": "quality", "measureId": "NHCR4", "title": "Repeat screening or surveillance colonoscopy recommended within one year due to inadequate bowel preparation", "description": "Percentage of patients recommended for repeat screening or surveillance colonoscopy or an alternate tier 1 or tier 2 colorectal cancer screening modality within one year or less due to inadequate bowel preparation quality", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "GIQuIC in Collaboration with American College of Gastroenterology, American Society for Gastrointestinal Endoscopy", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5846856" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_10", "title": "Care transition documentation practice improvements", "description": "In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1420", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_7", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1422", "M1423", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_8", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1421", "M1422", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_LGH_1", "title": "Lower Gastrointestinal Hemorrhage (groups only)", "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 Lower Gastrointestinal Hemorrhage episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract 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 35 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-lgi-bleed.pdf" }, "allowedPrograms": [ "mips", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_SSC_1", "title": "Screening/Surveillance Colonoscopy", "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 Screening/Surveillance Colonoscopy episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo a screening or surveillance colonoscopy procedure 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 14 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ss-clnscpy.pdf" }, "allowedPrograms": [ "mips", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_3", "title": "Electronic Case 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"M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1423", "clinicalTopic": "Urology Care", "title": "Optimal Care for Patients with Urologic Conditions", "description": "The Optimal Care for Patients with Urologic Conditions MVP focuses on assessing optimal care for patients treated for a broad range of urologic conditions, including kidney stones, urinary incontinence, bladder cancer, and prostate cancer.", "specialtiesMostApplicableTo": [ "Urology", "General Urologists", "Urology Oncologists", "Urology Care for Women", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Urology Care", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "050", "title": "Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "physicalTherapyOccupationalTherapy", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_050_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "318", "title": "Falls: Screening for Future Fall Risk", "description": "Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS139v14", "eMeasureUuid": "5cd5918e-b31d-4ecb-af3e-24923d0d594e", "nqfEMeasureId": null, "nqfId": "0101", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "audiology", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "orthopedicSurgery", "otolaryngology", "physicalTherapyOccupationalTherapy", "podiatry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0139v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were screened for future fall risk at least once within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "2EFD85A8-0F6A-4C9D-B500-B13559B6E000", "denominatorUuid": "45522BD1-875C-4C6D-BC3E-8CE25CA84D36", "numeratorUuid": "AF945143-9A66-47D6-819A-7C8463EF7E30", "denominatorExclusionUuid": "B58EC200-EE42-4105-A721-EDAFBFC7311C" } } ] }, { "category": "quality", "measureId": "321", "title": "CAHPS for MIPs Clinician/Group Survey", "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 CBE 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 CBE)\n• How well Providers Communicate; (Not endorsed by CBE)\n• Patient’s Rating of Provider; (CBE endorsed # 0005)\n• Access to Specialists; (Not endorsed by CBE)\n• Health Promotion and Education; (Not endorsed by CBE)\n• Shared Decision-Making; (Not endorsed by CBE) \n• Health Status and Functional Status; (Not endorsed by CBE)\n• Courteous and Helpful Office Staff; (CBE endorsed # 0005)\n• Care Coordination; (Not endorsed by CBE)\n• Stewardship of Patient Resources. (Not endorsed by CBE)", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M0005", "M1423", "M1503" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {}, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "358", "title": "Patient-Centered Surgical Risk Assessment and Communication", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423", "M1425", "M1502", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "orthopedicSurgery", "otolaryngology", "plasticSurgery", "podiatry", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_358_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "462", "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": "CMS645v9", "eMeasureUuid": "4536b54a-8ef4-418a-8944-d1426c6a58de", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Oregon Urology Institute", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "endocrinology", "oncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0645v9" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "786E05E4-F16E-492D-BAD4-2555F1CA3F40", "denominatorUuid": "B876332D-519E-444E-839F-7FA9C919F1A6", "numeratorUuid": "474E39BC-B7EA-4BBA-A7ED-62D50806F61D", "denominatorExceptionUuid": "34047550-15EF-4204-9A8F-A0285CFE8F4F" } } ] }, { "category": "quality", "measureId": "476", "title": "Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia", "description": "Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": "CMS771v7", "eMeasureUuid": "7e9ed220-274d-4f27-8ff0-6fd0cb482cf6", "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Large Urology Group Practice Association and Oregon Urology Institute", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0771v7" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "F5F30C86-7504-463A-822F-2A7773AD62E8", "denominatorUuid": "73DF06D9-B793-4CBC-85D5-AE7D396F23BD", "numeratorUuid": "A064DE1F-FC50-4199-AFC4-816074DA3E1F", "denominatorExclusionUuid": "4D96A847-9BCC-478A-A6E0-D01638CF5F00" } } ] }, { "category": "quality", "measureId": "481", "title": "Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer", "description": "Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": "CMS646v6", "eMeasureUuid": "a08c5ba7-6c2a-465b-8415-92861ee15fa4", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Oregon Urology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0646v6" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series: BCG is initiated within 6 months of the bladder cancer staging", "eMeasureUuids": { "initialPopulationUuid": "AA2E8D12-F5D5-49A4-B15A-5C16B5F18667", "denominatorUuid": "C3968A41-F665-4131-9EF4-E850845E2D1F", "numeratorUuid": "EAD93629-C7CB-4682-B599-EE13B03FEF38", "denominatorExceptionUuid": "D629A3FE-F02D-40A7-ACE3-99A465A9BE83", "denominatorExclusionUuid": "E1CA1D66-73AB-4CA4-997F-0CBACD08C4B4" } } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "AQUA14", "title": "Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment", "description": "Percentage of patients who underwent repeat Shock Wave Lithotripsy within 6 months of initial procedure", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA15", "title": "Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures", "description": "Percentage of patients with a documented urinalysis or urine culture within 14 days prior to surgical stone procedures", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA16", "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease", "description": "Percentage of patients with T1 disease who had a second transurethral resection of bladder tumor (TURBT) within 6 weeks of the initial TURBT", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA8", "title": "Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy", "description": "Percentage of patients with urinary retention, infection, inpatient consultation, or hospital admission for infection or sepsis within 30 days of undergoing a prostate biopsy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "MUSIC4", "title": "Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients", "description": "Proportion of patients newly diagnosed with low-risk prostate cancer managed with active surveillance or watchful waiting", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2014, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_17", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1423", "M1425", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_7", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1422", "M1423", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_17", "title": "Participation in Population Health Research", "description": "Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_21", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M0004", "M1423", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_12", "title": "Participation in private payer CPIA", "description": "Participation in designated private payer clinical practice improvement activities.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_21", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0004", "M1370", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_PC_1", "title": "Prostate Cancer episode-based cost measure", "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.\nThe Prostate Cancer episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat prostate cancer. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Prostate Cancer episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-prost-ca.pdf" }, "allowedPrograms": [ "mips", "M0001", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_RUSST_1", "title": "Renal or Ureteral Stone Surgical Treatment", "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 Renal or Ureteral Stone Surgical Treatment episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive surgical treatment for renal or ureteral stones during the performance period. The measure score is the clinician's risk\u0002adjusted 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 90 days prior to the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-rn-stone.pdf" }, "allowedPrograms": [ "mips", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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"PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1424", "clinicalTopic": "Pulmonology Care", "title": "Pulmonology Care", "description": "The Pulmonology Care MVP focuses on assessing optimal care for patients treated for a broad range of pulmonology conditions including COPD, asthma, sleep apnea, and general pulmonology.", "specialtiesMostApplicableTo": [ "Pulmonology", "Sleep Medicine", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Pulmonology Care", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "052", "title": "Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD with a documented FEV1/FVC <70% measured by spirometry, who are symptomatic and were prescribed a long-acting inhaled bronchodilator.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0102", "measureType": "process", "isHighPriority": false, "primarySteward": "American Thoracic Society", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_052_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "spirometry", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD who have a documented airflow obstruction (FEV1/FVC < 70%) as measured by spirometry." }, { "name": "bronchodilator", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD who have documented airflow obstruction (FEV1/FVC < 70%) and are symptomatic, who were prescribed a long-acting inhaled bronchodilator." } ] }, { "category": "quality", "measureId": "128", "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if BMI was outside of normal parameters.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS69v14", "eMeasureUuid": "6eabf62a-209b-4969-829e-04c502db761d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "G0055", "G0058", "M1367", "M1370", "M1424" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0069v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_128_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_128_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "5A321168-A454-4BD9-B82E-A403B009DE8F", "denominatorUuid": "7980B172-09ED-4A0C-B29C-D652DB845BF5", "numeratorUuid": "5AF09C9B-07A3-4BF4-A366-7AEA9C934050", "denominatorExceptionUuid": "5509373E-4ACA-4B71-8E56-E42BBB1A3880", "denominatorExclusionUuid": "50128A04-F2DD-4B6D-A078-B16904431CEC" } } ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "277", "title": "Sleep Apnea: Severity Assessment at Initial Diagnosis", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Sleep Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "otolaryngology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_277_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "279", "title": "Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available)", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Sleep Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "otolaryngology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_279_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "398", "title": "Optimal Asthma Control", "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "otolaryngology", "pediatrics", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_398_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "overall", "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "pedCtrlNoExactRisk", "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "adultCtrlNoExactRisk", "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "pedsWellCtrl", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma" }, { "name": "adultsWellCtrl", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma" }, { "name": "pedsNoRiskExact", "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma" }, { "name": "adultsNoRiskExact", "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma" } ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) 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.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 4 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 4 to 12 month period" } ] }, { "category": "quality", "measureId": "ACEP25", "title": "Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD", "description": "Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED and discharged who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_AHW_1", "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:\n• 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;\n• 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);\n• 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;\n• 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;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• 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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_23", "title": "Integration of patient coaching practices between visits", "description": "Provide coaching between visits with follow-up on care plan and goals.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_ACOPD_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-chron-copd.pdf" }, "allowedPrograms": [ "mips", "M0005", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_COPDE_1", "title": "Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation", "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 Inpatient COPD Exacerbation episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who receive inpatient treatment for an acute exacerbation of COPD 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 60 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ip-copd.pdf" }, "allowedPrograms": [ "mips", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_EX_3", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1425", "clinicalTopic": "Surgical Care", "title": "Surgical Care", "description": "The Surgical Care MVP focuses on the clinical theme of surgery.", "specialtiesMostApplicableTo": [ "General Surgery", "Neurosurgery", "Cardiothoracic Surgery", "Nonphysician Practitioners", "Nurse Practitioner", "Physician Assistants" ], "clinicalTopics": "Surgical Care", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "164", "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0129", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_164_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "167", "title": "Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0114", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_167_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "168", "title": "Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) for mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native vessel, graft or both), valve dysfunction, aortic reintervention or other cardiac reason during the current hospitalization.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0115", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_168_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "354", "title": "Anastomotic Leak Intervention", "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_354_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "355", "title": "Unplanned Reoperation within the 30-Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30-day postoperative period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_355_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "357", "title": "Surgical Site Infection (SSI)", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_357_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "358", "title": "Patient-Centered Surgical Risk Assessment and Communication", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423", "M1425", "M1502", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "orthopedicSurgery", "otolaryngology", "plasticSurgery", "podiatry", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_358_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "445", "title": "Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)", "description": "Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0119", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_445_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "459", "title": "Back Pain After Lumbar Surgery", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurosurgical", "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_459_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "lumbarDiscectomy", "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively" }, { "name": "lumbarFusion", "description": "Percentage of lumbar fusion procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric pain scale at one year (9 to 15 months) postoperatively" } ] }, { "category": "quality", "measureId": "461", "title": "Leg Pain After Lumbar Surgery", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurosurgical", "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_461_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "lumbarDiscectomy", "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports leg pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively" }, { "name": "lumbarFusion", "description": "Percentage of lumbar fusion procedures for which the patient reports leg pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at one year (9 to 15 months) postoperatively after lumbar fusion." } ] }, { "category": "quality", "measureId": "471", "title": "Functional Status After Lumbar Surgery", "description": "For patients age 18 and older who had lumbar discectomy/laminectomy or fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure. * hereafter referred to as ODI", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurosurgical", "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_471_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "lumbarDiscectomy", "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively" }, { "name": "lumbarFusion", "description": "Percentage of lumbar fusion procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively" } ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "G0059", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_17", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1423", "M1425", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_18", "title": "Relationship-Centered Communication", "description": "In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan. The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_8", "title": "Use of Patient Safety Tools", "description": "In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1421", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_CRR_1", "title": "Colon and Rectal Resection", "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 Colon and Rectal Resection episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive colon or rectal resection for either benign or malignant indications 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 15 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-colrec-rsct.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_FIHR_1", "title": "Femoral or Inguinal Hernia Repair", "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 Femoral or Inguinal Hernia Repair episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who undergo surgical procedure to repair a femoral or inguinal hernia 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.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-fihr.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_LPMSM_1", "title": "Lumpectomy, Partial Mastectomy, Simple Mastectomy", "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 Lumpectomy, Partial Mastectomy, Simple Mastectomy episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo partial or total mastectomy for breast cancer 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.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-lump-mast.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_LSFDD_1", "title": "Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels", "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 Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo surgery for lumbar spine fusion during the performance period. The measure score is the clinician's risk\u0002adjusted 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.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-l-fusion.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_NECABG_1", "title": "Non-Emergent Coronary Artery Bypass Graft (CABG)", "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 Non-Emergent CABG episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo a CABG procedure 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.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ne-cabg.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1498", "clinicalTopic": "Diagnostic Radiology", "title": "Diagnostic Radiology", "description": "The Diagnostic Radiology MVP assesses meaningful outcomes in diagnostic radiology.", "specialtiesMostApplicableTo": [ "Diagnostic Radiology" ], "clinicalTopics": "Diagnostic Radiology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "145", "title": "Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy", "description": "Final reports for procedures using fluoroscopy that document radiation exposure indices.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498", "M1499" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology", "interventionalRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_145_MedicarePartBclaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_145_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "360", "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies", "description": "Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion or infarct avid imaging) reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion or infarct avid imaging) studies that the patient has received in the 12-month period prior to the current study.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_360_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "364", "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines", "description": "Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_364_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "405", "title": "Appropriate Follow-up Imaging for Incidental Abdominal Lesions", "description": "Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow‐up imaging recommended based on radiological findings:\n• Cystic renal lesion that is simple appearing* (Bosniak I or II)\n• Adrenal lesion less than or equal to 1.0 cm\n• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_405_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_405_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "406", "title": "Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients", "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_406_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_406_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "494", "title": "Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)", "description": "This measure provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of patients with CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality relative to evidence-based thresholds based on the clinical indication for the exam. All diagnostic CT exams of specified anatomic sites performed in inpatient, outpatient and ambulatory care settings are eligible. This measure is not telehealth eligible. This eCQM requires the use of additional software to access primary data elements stored within radiology electronic health records and translate them into data elements that can be ingested by this eCQM. Additional details are included in the Guidance field.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": "CMS1056v3", "eMeasureUuid": "1463d715-c1d7-49de-8473-348ce1fc81ca", "nqfEMeasureId": "3633e", "nqfId": "3633e\n3662e", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Alara Imaging, Inc. in collaboration with the University of California, San Francisco (UCSF)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1056v3" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with one or more eligible CT scans with calculated CT Size-Adjusted Dose greater than or equal to a threshold specific to the CT Dose and Image Quality Category, or Calculated CT Global Noise value greater than or equal to a threshold specific to the CT Dose and Image Quality Category", "eMeasureUuids": { "initialPopulationUuid": "1FFCCC84-6F19-4B0A-9DF0-6B851CE34C24", "denominatorUuid": "B6F347A2-7768-4D3F-96E5-5DECFCDA059F", "numeratorUuid": "BA85E0B1-3886-4000-B694-8D0E158731C5", "denominatorExclusionUuid": "2E1C63E1-5790-4E94-9081-ACA574B3DB47" } } ] }, { "category": "quality", "measureId": "QMM17", "title": "Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS)", "description": "The percentage of final reports for female patients receiving a transvaginal ultrasound (US) examination of the pelvis (including transabdominal/transvaginal exams) where a lesion is detected, in which the radiologist describes the lesion using ORADS Lexicon Descriptors, provides ORADS score, and subsequently makes the correct clinical management recommendation based on the ORADS Risk Stratification and Management System.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM18", "title": "Use of Breast Cancer Risk Score on Mammography", "description": "The percentage of final reports for screening mammograms which include the patient’s estimated numeric risk assessment based on a valid and published model**, and appropriate recommendations for supplemental screening based on the patient’s estimated risk and documentation of the source of recommendation.\n** Must be one of the models listed in the numerator instructions of this measure specification.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM26", "title": "Screening Abdominal Aortic Aneurysm Reporting with Recommendations", "description": "Percentage of patients, aged 50-years-old or older, who have had a screening ultrasound for an abdominal aortic aneurysm (AAA), with positive or negative findings, that have recognized clinical follow-up recommendations documented in the final report and direct communication of findings greater than or equal to 5.5 cm in size made to the ordering provider.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_19", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_7", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1422", "M1423", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_8", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_12", "title": "Participation in private payer CPIA", "description": "Participation in designated private payer clinical practice improvement activities.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_2", "title": "Participation in MOC Part IV", "description": "In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1499", "clinicalTopic": "Interventional Radiology", "title": "Interventional Radiology", "description": "The Interventional Radiology MVP assesses meaningful outcomes in vascular, dialysis, neurological, and general interventional radiology care.", "specialtiesMostApplicableTo": [ "Interventional Radiology" ], "clinicalTopics": "Interventional Radiology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "145", "title": "Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy", "description": "Final reports for procedures using fluoroscopy that document radiation exposure indices.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498", "M1499" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology", "interventionalRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_145_MedicarePartBclaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_145_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "374", "title": "Closing the Referral Loop: Receipt of Specialist Report", "description": "Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS50v14", "eMeasureUuid": "2af15f05-07a9-4f5c-9a40-11ea768adcda", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420", "M1422", "M1499", "M1502", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "internalMedicine", "interventionalRadiology", "neurology", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0050v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_374_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients with a referral on or before October 31, for which the referring clinician received a report from the first clinician to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "D36BF246-D75C-41C1-B4F6-FA174EC27C0D", "denominatorUuid": "894E9268-7EE5-4E26-BF65-4256C215414D", "numeratorUuid": "B5A8F06A-68CE-428F-8FBA-FCCEE730ED0C" } } ] }, { "category": "quality", "measureId": "413", "title": "Door to Puncture Time for Endovascular Stroke Treatment", "description": "Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_413_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "420", "title": "Varicose Vein Treatment with Saphenous Ablation: Outcome Survey", "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_420_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "421", "title": "Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal", "description": "Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_421_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "465", "title": "Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries", "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_465_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "RCOIR12", "title": "Tunneled Hemodialysis Catheter Clinical Success Rate", "description": "Percentage of tunneled central venous access catheter insertions or replacements that resulted in successful dialysis treatment in patients with end-stage renal disease (ESRD).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RCOIR13", "title": "Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate", "description": "Percentage of clinically successful percutaneously created arteriovenous fistulae (pAVF) for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RPAQIR14", "title": "Arteriovenous Graft Thrombectomy Clinical Success Rate", "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RPAQIR15", "title": "Arteriovenous Fistulae Thrombectomy Clinical Success Rate", "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_1", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "G0059", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_17", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1423", "M1425", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_19", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_7", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1422", "M1423", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_8", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_3", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_8", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1421", "M1422", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_17", "title": "Participation in Population Health Research", "description": "Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_18", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1499", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_25", "title": "Cost Display for Laboratory and Radiographic Orders", "description": "Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_HAC_1", "title": "Hemodialysis Access Creation", "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 Hemodialysis Access Creation episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis 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 60 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-hd-access.pdf" }, "allowedPrograms": [ "mips", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_IHCI_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ich-cva.pdf" }, "allowedPrograms": [ "mips", "G0054", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1500", "clinicalTopic": "Neuropsychology", "title": "Neuropsychology", "description": "The Neuropsychology MVP assesses meaningful outcomes in patients receiving neuropsychological care.", "specialtiesMostApplicableTo": [ "Neuropsychology", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Neuropsychology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and Follow-Up Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS2v15", "eMeasureUuid": "fbaecc84-b452-4188-95a6-21246e8ca619", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "134SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0005", "M1366", "M1368", "M1369", "M1370", "M1500" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "oncology", "orthopedicSurgery", "pediatrics", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0002v15", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_134_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_134_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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 or an active depression medication overlaps the date of the qualifying encounter", "eMeasureUuids": { "initialPopulationUuid": "30EC0533-2579-4CC6-A86D-5B0051C34604", "denominatorUuid": "661C22C5-CAA6-4F30-AE68-6FA59C265128", "numeratorUuid": "BD02B228-9DE9-447F-A343-0B3BDE778D22", "denominatorExceptionUuid": "21918DA5-4EA0-4B07-B676-6F26CBD3138A", "denominatorExclusionUuid": "C22233F9-6C86-4C17-B212-3F1BD3312144" } } ] }, { "category": "quality", "measureId": "181", "title": "Elder Maltreatment Screen and Follow-Up Plan", "description": "Percentage of patients aged 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1500" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "emergencyMedicine", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "physicalTherapyOccupationalTherapy", "skilledNursingFacility", "speechLanguagePathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_181_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_181_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "282", "title": "Dementia: Functional Status Assessment", "description": "Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_282_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "286", "title": "Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_286_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "288", "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "nutritionDietician", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_288_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_22", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_21", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M0004", "M1423", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", 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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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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 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"M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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. 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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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1501", "clinicalTopic": "Pathology", "title": "Pathology", "description": "The Pathology MVP assesses meaningful outcomes in pathology.", "specialtiesMostApplicableTo": [ "Pathology" ], "clinicalTopics": "Pathology", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "249", "title": "Barrett's Esophagus", "description": "Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_249_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_249_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "250", "title": "Radical Prostatectomy Pathology Reporting", "description": "Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "oncology", "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_250_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_250_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "395", "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)", "description": "Pathology reports based on lung biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type following the International Association for the Study of Lung Cancer (IASLC) guidance or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_395_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_395_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "396", "title": "Lung Cancer Reporting (Resection Specimens)", "description": "Pathology reports based on lung resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_396_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_396_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "397", "title": "Melanoma Reporting", "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_397_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_397_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "440", "title": "Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician", "description": "Percentage of biopsies with a diagnosis of cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_440_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "491", "title": "Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status", "description": "Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3661", "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_491_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "CAP30", "title": "Urinary Bladder Cancer: Complete Analysis and Timely Reporting", "description": "Percentage of urinary bladder carcinoma pathology reports that include the procedure, histologic tumor grade, histologic type, presence/absence of muscularis propria, presence/absence of lymphovascular invasion, and tumor extent. \nAND \nmeet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date is less than or equal to 2 business days). \n\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\nStratum 1.\tPercent of cases for which all required data elements of the urinary bladder carcinoma pathology report are included.\nStratum 2.\tPercent of cases that meet the maximum 2 business day turnaround time.\nThe overall performance score submitted is a weighted average of: \n(Performance rate 1 x 70%)+(Performance rate 2 x 30%)", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP34", "title": "Molecular Assessment: Biomarkers in Non-Small Cell Lung Cancer", "description": "Percentage of non-small cell lung cancer (NSCLC) pathology reports that include anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR), AND tyrosine protein kinase ROS1 mutation status.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP40", "title": "Squamous Cell Skin Cancer: Complete Reporting", "description": "Percentage of final pathology reports for excisions for squamous cell carcinoma of the skin that include a comment on margin status, degree of differentiation/histologic grade, depth or level of invasion, presence of perineural invasion* and presence of lymphovascular invasion\r\n\r\n*Perineural invasion defined as tumor cells within the nerve sheath of a nerve deep to the dermis or with a caliber of 0.1 mm or higher.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "QMM21", "title": "Incorporating results of concurrent studies into Final Reports for Bone Marrow Aspirate of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia", "description": "The percentage of Final Bone Marrow Aspirate Reports of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia with documentation of concurrent studies performed, their respective results, and interpretation of those results.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330", "6704504" ] }, { "category": "quality", "measureId": "QMM25", "title": "Use of Structured Reporting for Urine Cytology Specimens", "description": "The percentage of Final Reports on Urine cytology specimens, for patients of any age, that utilize The Paris System (TPS) for reporting urinary cytology.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330", "6704504" ] }, { "category": "quality", "measureId": "QMM29", "title": "Use of Appropriate Classification System for Lymphoma Specimen", "description": "Percentage of Final Lymphoma Specimen Pathology Reports, regardless of patient age, that classify the lymphoma using a validated and published model for lymphoma classification**. \n \n** Must be one of the models listed in the Numerator Instructions below.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330" ] }, { "category": "quality", "measureId": "QMM30", "title": "Appropriate Use of Bethesda System for Reporting Thyroid Cytopathology on Fine Needle Aspirations (FNA) of Thyroid Nodule(s)", "description": "Percentage of final pathology reports for thyroid nodule fine needle aspiration (FNA) specimens that include documentation of the diagnostic category, range of estimated risk of malignancy (ROM), and clinical management options in accordance with the Bethesda System for Reporting Cytopathology, 3rd edition (2023), and for thyroid nodule specimens of indeterminate cytology (Bethesda 3 or 4), documentation that direct communication was sent to patient and/or treating physician (if known) to inform them that molecular panel testing may be appropriate.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330", "6704504" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_19", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_12", "title": "Participation in private payer CPIA", "description": "Participation in designated private payer clinical practice improvement activities.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_13", "title": "Participation in Joint Commission Evaluation Initiative", "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_2", "title": "Participation in MOC Part IV", "description": "In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_35", "title": "Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data", "description": "Use security labeling services available in certified Health Information Technology (IT) for electronic health record (EHR) data to facilitate data segmentation. Certification criteria for security tags may be found in the ONC Health IT Certification Program at 45 CFR 170.315(b)(7) and (b)(8).", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1502", "clinicalTopic": "Podiatry", "title": "Podiatry", "description": "The Podiatry MVP assesses meaningful outcomes in foot and ankle care for patients with chronic conditions, wound/ulcers, and general care for the podiatry patient.", "specialtiesMostApplicableTo": [ "Podiatry", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Podiatry", "hasCahps": false, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "126", "title": "Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Podiatric Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_126_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "127", "title": "Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Podiatric Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [ "physicalTherapyOccupationalTherapy", "podiatry" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_127_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "155", "title": "Falls: Plan of Care", "description": "Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0101", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "familyMedicine", "geriatrics", "internalMedicine", "neurology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_155_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "317", "title": "Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented", "description": "Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS22v14", "eMeasureUuid": "d237ec57-5948-481a-998c-00acf9ba3fce", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "dermatology", "emergencyMedicine", "gastroenterology", "generalSurgery", "mentalBehavioralHealth", "nephrology", "neurology", "oncology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "rheumatology", "skilledNursingFacility", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0022v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_317_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_317_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive", "eMeasureUuids": { "initialPopulationUuid": "87F6429F-3797-476F-B687-77CD39427752", "denominatorUuid": "6D261A32-07A6-4C55-A749-02DFC583279E", "numeratorUuid": "1E7D8735-2DE2-45EC-9B7E-F32D049238FA", "denominatorExceptionUuid": "8D49EFFA-E657-44A2-8C6F-7AA726D8CDE2", "denominatorExclusionUuid": "03B6691C-3D31-454C-838D-0EB94DC615F8" } } ] }, { "category": "quality", "measureId": "358", "title": "Patient-Centered Surgical Risk Assessment and Communication", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423", "M1425", "M1502", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "orthopedicSurgery", "otolaryngology", "plasticSurgery", "podiatry", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_358_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "374", "title": "Closing the Referral Loop: Receipt of Specialist Report", "description": "Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS50v14", "eMeasureUuid": "2af15f05-07a9-4f5c-9a40-11ea768adcda", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420", "M1422", "M1499", "M1502", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "internalMedicine", "interventionalRadiology", "neurology", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0050v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_374_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients with a referral on or before October 31, for which the referring clinician received a report from the first clinician to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "D36BF246-D75C-41C1-B4F6-FA174EC27C0D", "denominatorUuid": "894E9268-7EE5-4E26-BF65-4256C215414D", "numeratorUuid": "B5A8F06A-68CE-428F-8FBA-FCCEE730ED0C" } } ] }, { "category": "quality", "measureId": "MEX5", "title": "Hammer Toe Outcome", "description": "Percentage of patients with a who have a lesser toe deformity (hammer and claw toes) causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR1", "title": "Heel Pain Treatment Outcomes for Adults", "description": "Percentage of patients aged 18 and older with a diagnosis of heel pain who receive an intervention intended to treat the heel pain and experience a clinically significant decrease in heel pain.\r\nPatients who have had at least two visits during the reporting period", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR3", "title": "Bunion Outcome - Adult and Adolescent", "description": "Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR5", "title": "Offloading with Remote Monitoring", "description": "Percentage of patients with a plantar foot ulcer who were compliant with offloading and healed their ulcer in 10 (ten) weeks.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR8", "title": "Monitor and Improve Treatment Outcomes in Chronic Wound Healing", "description": "This measure is specifically for CHRONIC wounds. Those are wounds that have been present for an extended period of time and have not demonstrated healing. \nPercentage of patients presenting with a non-healing (chronic) wound (present for 6 weeks with no or limited response to treatment) who are currently visiting a provider responsible for their wound care, who performs a re-assessment of the wound (The use of digital imaging to monitor the wound is encouraged) , and has used the information learned from that re-assessment to implement a change in treatment plan, and whose wound healing rate has accelerated since implementation of the updated treatment plan.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "USWR32", "title": "Adequate Compression at each visit for Patients with Venous Leg Ulcers (VLUs) appropriate to arterial supply", "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older in which adequate compression is performed at each treatment visit during the 12-month reporting period. Arterial status must first be assessed to ensure that compression can be implemented safely.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338", "1718371" ] }, { "category": "quality", "measureId": "USWR33", "title": "Diabetic Foot Ulcer (DFU) Healing or Closure", "description": "Percentage of diabetic foot ulcers that have achieved healing or closure within 6 months, stratified by the Wound Healing Index.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338" ] }, { "category": "quality", "measureId": "USWR34", "title": "Venous Leg Ulcer (VLU) Healing or Closure", "description": "Percentage of venous leg ulcers among patients aged 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338" ] }, { "category": "quality", "measureId": "USWR35", "title": "Adequate Off-loading of Diabetic Foot Ulcers performed at each visit, appropriate to location of ulcer", "description": "Percentage of visits in which diabetic foot ulcers received adequate off-loading during the 12-month reporting period, appropriate to the location of the ulcer. (Off-loading is not a simple documentation process but may include performing a procedure such as Total Contact Casting or special bandaging.)", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338", "1718371" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_6", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "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.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_19", "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.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "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).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_14", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "M0001", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_18", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1499", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_22", "title": "CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain", "description": "Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_23", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] }, { "mvpId": "M1503", "clinicalTopic": "Vascular Surgery", "title": "Vascular Surgery", "description": "The Vascular Surgery MVP assesses meaningful outcomes in surgical, interventional, and general vascular surgery, and patient’s experience of care.", "specialtiesMostApplicableTo": [ "Vascular Surgery", "Nonphysician Practitioners", "Nurse Practitioners", "Physician Assistants" ], "clinicalTopics": "Vascular Surgery", "hasCahps": true, "hasOutcomeAdminClaims": false, "qualityMeasures": [ { "category": "quality", "measureId": "001", "title": "Diabetes: Glycemic Status Assessment Greater Than 9%", "description": "Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS122v14", "eMeasureUuid": "9700a8b9-9f65-41a8-8464-1da26cda857b", "nqfEMeasureId": null, "nqfId": "0059", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "001SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0005", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0122v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_001_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_001_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "51D8CA9A-E511-4793-8AD4-EFAE90F3ABA4", "denominatorUuid": "EA65F958-962E-433B-A9A3-CC2EA7B76E26", "numeratorUuid": "10C65EBE-685C-48F8-8B24-351C6F3481E9", "denominatorExclusionUuid": "CA386077-1F7A-4C23-85D7-33A4FCED0803" } } ] }, { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "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": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "130", "title": "Documentation of Current Medications in the Medical Record", "description": "Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS68v15", "eMeasureUuid": "7f7cb55d-35b9-4032-a33d-9f28562d795b", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0004", "M1368", "M1420", "M1422", "M1500", "M1503" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "infectiousDisease", "internalMedicine", "interventionalRadiology", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "preventiveMedicine", "pulmonology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "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": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { "initialPopulationUuid": "D9BEF0F0-26B4-484C-AF92-252622D46734", "denominatorUuid": "5455BCAD-B7A1-4F2E-85FF-EAE0881B7666", "numeratorUuid": "333A53EF-9CFF-4AC2-9F71-BA7010DBA9ED", "denominatorExclusionUuid": "64F71C4C-5F42-479C-9EDF-968EBCCFEDE7" }, "name": "combinedPopulations" } ] }, { "category": "quality", "measureId": "259", "title": "Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)", "description": "Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society for Vascular Surgery", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_259_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "321", "title": "CAHPS for MIPs Clinician/Group Survey", "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 CBE 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 CBE)\n• How well Providers Communicate; (Not endorsed by CBE)\n• Patient’s Rating of Provider; (CBE endorsed # 0005)\n• Access to Specialists; (Not endorsed by CBE)\n• Health Promotion and Education; (Not endorsed by CBE)\n• Shared Decision-Making; (Not endorsed by CBE) \n• Health Status and Functional Status; (Not endorsed by CBE)\n• Courteous and Helpful Office Staff; (CBE endorsed # 0005)\n• Care Coordination; (Not endorsed by CBE)\n• Stewardship of Patient Resources. (Not endorsed by CBE)", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M0005", "M1423", "M1503" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {}, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "344", "title": "Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "description": "Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) without major complication who are discharged to home no later than post-operative day #2.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society for Vascular Surgery", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "neurosurgical", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_344_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "355", "title": "Unplanned Reoperation within the 30-Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30-day postoperative period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_355_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "356", "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "plasticSurgery", "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_356_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "357", "title": "Surgical Site Infection (SSI)", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_357_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "358", "title": "Patient-Centered Surgical Risk Assessment and Communication", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423", "M1425", "M1502", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "orthopedicSurgery", "otolaryngology", "plasticSurgery", "podiatry", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_358_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "374", "title": "Closing the Referral Loop: Receipt of Specialist Report", "description": "Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS50v14", "eMeasureUuid": "2af15f05-07a9-4f5c-9a40-11ea768adcda", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420", "M1422", "M1499", "M1502", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "internalMedicine", "interventionalRadiology", "neurology", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0050v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_374_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients with a referral on or before October 31, for which the referring clinician received a report from the first clinician to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "D36BF246-D75C-41C1-B4F6-FA174EC27C0D", "denominatorUuid": "894E9268-7EE5-4E26-BF65-4256C215414D", "numeratorUuid": "B5A8F06A-68CE-428F-8FBA-FCCEE730ED0C" } } ] }, { "category": "quality", "measureId": "438", "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "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.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS347v9", "eMeasureUuid": "22ea0c5f-5a85-422b-8089-91c24c31bcbb", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M0005", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0347v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_438_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: - All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR - 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; OR - Patients aged 40-75 years with a diagnosis of diabetes; OR - Patients aged 40 to 75 with a 10-year ASCVD risk score of >= 20 percent.", "eMeasureUuids": { "initialPopulationUuid": "DC7EE1FA-285A-447A-AB71-621A180BECBB", "denominatorUuid": "F5A7F615-7471-4549-88FD-C8B447C9685F", "numeratorUuid": "E87BD132-0762-43F1-B61F-427E13BBE7FD", "denominatorExceptionUuid": "5F2E3CBA-C623-492F-8590-A298A5A5240D", "denominatorExclusionUuid": "589CFFC5-DA6E-4A83-822F-97A5025D400B" } } ] }, { "category": "quality", "measureId": "RCOIR12", "title": "Tunneled Hemodialysis Catheter Clinical Success Rate", "description": "Percentage of tunneled central venous access catheter insertions or replacements that resulted in successful dialysis treatment in patients with end-stage renal disease (ESRD).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RCOIR13", "title": "Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate", "description": "Percentage of clinically successful percutaneously created arteriovenous fistulae (pAVF) for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RPAQIR14", "title": "Arteriovenous Graft Thrombectomy Clinical Success Rate", "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RPAQIR15", "title": "Arteriovenous Fistulae Thrombectomy Clinical Success Rate", "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] } ], "iaMeasures": [ { "category": "ia", "measureId": "IA_BE_1", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new 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, the following: 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; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "G0059", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_3", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_8", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1421", "M1422", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "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.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_15", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_2", "title": "Anticoagulant Management Improvements", "description": "Individual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities:• Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program);• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; or• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_21", "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.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M0004", "M1423", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_5", "title": "Engagement of community for health status improvement", "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "costMeasures": [ { "category": "cost", "measureId": "COST_CCLI_1", "title": "Revascularization for Lower Extremity Chronic Critical Limb Ischemia", "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 Revascularization for Lower Extremity Chronic Critical Limb Ischemia episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia 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.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-rleccli.pdf" }, "allowedPrograms": [ "mips", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_HAC_1", "title": "Hemodialysis Access Creation", "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 Hemodialysis Access Creation episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis 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 60 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-hd-access.pdf" }, "allowedPrograms": [ "mips", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "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.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization registry/immunization information system (IIS).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_1_PRE", "PI_PHCDRR_1_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_2_PRE", "PI_PHCDRR_2_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_3_PRE", "PI_PHCDRR_3_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_1", "PI_PHCDRR_3_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "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.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "foundationQualityMeasures": [ { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "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.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ], "administrativeClaimsMeasures": [] } ]