- Quality - 65% of total MIPS 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:076NQF:eMeasure ID:High Priority:Yes
2021 MIPS Measure #076: Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
Measure Type- Process
SpecificationsSpecialty- Anesthesiology
- Hospitalists
- Interventional Radiology
ID:145NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #145: Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
- Interventional Radiology
ID:374NQF:eMeasure ID:CMS50v9High Priority:Yes2021 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Interventional Radiology
- Mental/Behavioral Health
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:409NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #409: Clinical Outcome Post Endovascular Stroke Treatment
Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention
Measure Type- Outcome
SpecificationsSpecialty- Interventional Radiology
- Neurosurgery
ID:413NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #413: Door to Puncture Time for Endovascular Stroke Treatment
Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours
Measure Type- Intermediate Outcome
SpecificationsSpecialty- Interventional Radiology
- Neurosurgery
ID:420NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #420: Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
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
Measure Type- Outcome
SpecificationsSpecialty- Interventional Radiology
- Vascular Surgery
ID:421NQF:eMeasure ID:High Priority:No2021 MIPS Measure #421: Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
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
Measure Type- Process
SpecificationsSpecialty- Interventional Radiology
ID:465NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #465: Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries
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
Measure Type- Process
SpecificationsSpecialty- Interventional Radiology
- *These measures make up the Interventional Radiology Specialty Measures Set.
- IA: Improvement Activities - 15% of total MIPS 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 measures to choose from. The following are some suggestions:
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements(medium weighted).
- IA_CC_13 - Practice improvements for bilateral exchange of patient information (medium weighted).
- IA_PSPA_18 - Measurement and improvement at the practice and panel level (medium weighted).
- IA_PSPA_19 - Implementation of formal quality improvement methods, practice changes or other practice improvement processes (medium weighted).
- IA_PSPA_20 - Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes (medium weighted).
