- 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:145NQF:eMeasure ID:High Priority:Yes
2021 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:147NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #147: Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
ID:195NQF:0507eMeasure ID:High Priority:No2021 MIPS Measure #195: Radiology: Stenosis Measurement in Carotid Imaging Reports
Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
ID:225NQF:0509eMeasure ID:High Priority:Yes2021 MIPS Measure #225: Radiology: Reminder System for Screening Mammograms
Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram
Measure Type- Structure
SpecificationsSpecialty- Diagnostic Radiology
ID:360NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) 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) studies that the patient has received in the 12-month period prior to the current study
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
ID:364NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
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)
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
ID:405NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions
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:
- Cystic renal lesion that is simple appearing* (Bosniak I or II)
- Adrenal lesion less than or equal to 1.0 cm
- 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
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
ID:406NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
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
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
ID:436NQF:eMeasure ID:High Priority:No2021 MIPS Measure #436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Percentage of final reports for patients aged 18 years and older undergoing computed tomography (CT) with documentation that one or more of the following dose reduction techniques were used
- Automated exposure control
- Adjustment of the mA and/or kV according to patient size
- Use of iterative reconstruction technique
Measure Type- Process
SpecificationsSpecialty- Diagnostic Radiology
- 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 activities to choose from. The following are some suggestions:
- IA_BE_6 - Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (high weighted).
- IA_BE_12 - Use evidence-based decision aids to support shared decision-making (medium weighted).
- IA_CC_1 - Implementation of use of specialist reports back to referring clinician or group to close referral loop (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- IA_PSPA_1 - Participation in an AHRQ-listed patient safety organization. (medium weighted).
- IA_PSPA_2 - Participation in MOC Part IV. (medium weighted).
- IA_PSPA_16 - Use of decision support and standardized treatment protocols (medium weighted).
- IA_PSPA_19 - Implementation of formal quality improvement methods, practice changes or other practice improvement processes (medium weighted).
