- 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:023NQF:0239eMeasure ID:High Priority:Yes
2021 MIPS Measure #023: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
Measure Type- Process
SpecificationsSpecialty- General Surgery
- Neurosurgery
- Orthopedic Surgery
- Otolaryngology
- Plastic Surgery
- Thoracic Surgery
- Urology
- Vascular Surgery
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:048NQF:eMeasure ID:High Priority:No2021 MIPS Measure #048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- Urology
ID:050NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
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
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Urology
ID:102NQF:0389eMeasure ID:CMS129v10High Priority:Yes2021 MIPS Measure #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
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
Measure Type- Process
Specialty- Oncology/Hematology
- Radiation Oncology
- Urology
ID:104NQF:0390eMeasure ID:High Priority:No2021 MIPS Measure #104: Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate
Measure Type- Process
SpecificationsSpecialty- Urology
ID:119NQF:0062eMeasure ID:CMS134v9High Priority:No2021 MIPS Measure #119: Diabetes: Medical Attention for Nephropathy
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Measure Type- Process
Specialty- Endocrinology
- Family Medicine
- Internal Medicine
- Nephrology
- Preventive Medicine
- Urology
ID:128NQF:0421eMeasure ID:CMS69v9High Priority:No2021 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
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 most recent BMI was outside of normal parameters
Measure Type- Process
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nutrition/Dietician
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
- Vascular Surgery
ID:130NQF:0419eeMeasure ID:CMS68v10High Priority:Yes2021 MIPS Measure #130: Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
Measure Type- Process
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- Clinical Social Work
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Geriatrics
- Hospitalists
- Infectious Disease
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Neurosurgery
- Nutrition/Dietician
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Preventive Medicine
- Pulmonology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:226NQF:0028eMeasure ID:CMS138v9High Priority:No2021 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user
Measure Type- Process
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- Clinical Social Work
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Neurosurgery
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:265NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #265: Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient
Measure Type- Process
SpecificationsSpecialty- Dermatology
- Obstetrics/Gynecology
- Otolaryngology
- Urology
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:358NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #358: Patient-Centered Surgical Risk Assessment and Communication
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
Measure Type- Process
SpecificationsSpecialty- General Surgery
- Orthopedic Surgery
- Otolaryngology
- Plastic Surgery
- Thoracic Surgery
- Urology
- Vascular Surgery
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:429NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #429: Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy
Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse
Measure Type- Process
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:431NQF:2152eMeasure ID:High Priority:No2021 MIPS Measure #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
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
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Clinical Social Work
- Family Medicine
- Gastroenterology
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Nutrition/Dietician
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Urgent Care
- Urology
ID:432NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:433NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:434NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #434: Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:462NQF:eMeasure ID:CMS645v4High Priority:No2021 MIPS Measure #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
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.
Measure Type- Process
SpecificationsSpecialty- Endocrinology
- Oncology/Hematology
- Urology
ID:476NQF:eMeasure ID:CMS771v2High Priority:Yes2021 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
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.
Measure Type- Outcome
SpecificationsSpecialty- Geriatrics
- Urology
- 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).