- Quality - 40% of total score: Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to possibly earn more than 3 points on a measure. Note: Small practices (less than 16 in the practice) can earn 3 points on a measure if at least 1 eligible case is reported. Suggestions for your specialty include, but are not limited to, the following: ID:006NQF:0067eMeasure ID:High Priority:No
2021 MIPS Measure #006: Coronary Artery Disease (CAD): Antiplatelet Therapy
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
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Family Medicine
- Internal Medicine
- Skilled Nursing Facility
ID:007NQF:0070eMeasure ID:CMS145v9High Priority:No2021 MIPS Measure #007: Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
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
Measure Type- Process
Specialty- Cardiology
- Family Medicine
- Internal Medicine
- Skilled Nursing Facility
ID:008NQF:0083eMeasure ID:CMS144v9High Priority:No2021 MIPS Measure #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
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
Measure Type- Process
Specialty- Cardiology
- Family Medicine
- Hospitalists
- Internal Medicine
- Skilled Nursing Facility
ID:047NQF:0326eMeasure ID:High Priority:Yes2021 MIPS Measure #047: Advance Care Plan
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
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Clinical Social Work
- Family Medicine
- Gastroenterology
- General Surgery
- Geriatrics
- Hospitalists
- Internal Medicine
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:110NQF:0041eMeasure ID:CMS147v10High Priority:No2021 MIPS Measure #110: Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Endocrinology
- Family Medicine
- Geriatrics
- Infectious Disease
- Internal Medicine
- Nephrology
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Pediatrics
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
ID:111NQF:0043eMeasure ID:CMS127v9High Priority:No2021 MIPS Measure #111: Pneumococcal Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Endocrinology
- Family Medicine
- Geriatrics
- Infectious Disease
- Internal Medicine
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
ID:118NQF:0066eMeasure ID:High Priority:No2021 MIPS Measure #118: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
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
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Endocrinology
- Skilled Nursing Facility
ID:154NQF:0101eMeasure ID:High Priority:Yes2021 MIPS Measure #154: Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
Measure Type- Process
SpecificationsSpecialty- Audiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Neurology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Skilled Nursing Facility
ID:155NQF:0101eMeasure ID:High Priority:Yes2021 MIPS Measure #155: Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
Measure Type- Process
SpecificationsSpecialty- Audiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Neurology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Skilled Nursing Facility
ID:181NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #181: Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Measure Type- Process
SpecificationsSpecialty- Audiology
- Clinical Social Work
- Family Medicine
- Geriatrics
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Nutrition/Dietician
- Physical Therapy/Occupational Therapy
- Skilled Nursing Facility
- Speech/Language Pathology
ID:238NQF:0022eMeasure ID:CMS156v9High Priority:Yes2021 MIPS Measure #238: Use of High-Risk Medications in the Elderly
Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Ophthalmology
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
ID:317NQF:eMeasure ID:CMS22v9High Priority:No2021 MIPS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
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 pre-hypertensive or hypertensive
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Emergency Medicine
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Plastic Surgery
- Preventive Medicine
- Rheumatology
- Skilled Nursing Facility
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:326NQF:1525eMeasure ID:High Priority:No2021 MIPS Measure #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Family Medicine
- Internal Medicine
- Skilled Nursing Facility
- PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 2021. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 65% of your score.
- e-Prescribing
- Query of Prescription Drug Monitoring Program (PDMP) (optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops by Sending Health Information
- Support Electronic Referral Loops by Receiving and Incorporating Health Information
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- IA: Improvement Activities - 15% of total score: Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year. There are over 100 possible activities to choose from. The following are suggestions only:
- IA_EPA_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_AHE_1 - Engagement of new Medicaid patients and follow-up (high weighted).
- IA_BE_14 - Engage patients and families to guide improvement in the system of care (high weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).