MIPS Measures Relevant to Otolaryngology

  1. 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:
    021
    NQF:
    0268
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #021: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin

    Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Neurosurgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Vascular Surgery
    ID:
    023
    NQF:
    0239
    eMeasure 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
    Specifications
    Specialty
    • General Surgery
    • Neurosurgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    047
    NQF:
    0326
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • 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:
    065
    NQF:
    0069
    eMeasure ID:
    CMS154v9
    High Priority:
    Yes

    2021 MIPS Measure #065: Appropriate Treatment for Upper Respiratory Infection (URI)

    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 dispensing event

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:
    093
    NQF:
    0654
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #093: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

    Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:
    110
    NQF:
    0041
    eMeasure ID:
    CMS147v10
    High Priority:
    No

    2021 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
    Specifications
    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:
    111
    NQF:
    0043
    eMeasure ID:
    CMS127v9
    High Priority:
    No

    2021 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
    Specifications
    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:
    128
    NQF:
    0421
    eMeasure ID:
    CMS69v9
    High Priority:
    No

    2021 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
    Specifications
    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:
    130
    NQF:
    0419e
    eMeasure ID:
    CMS68v10
    High Priority:
    Yes

    2021 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
    Specifications
    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:
    154
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    155
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    226
    NQF:
    0028
    eMeasure ID:
    CMS138v9
    High Priority:
    No

    2021 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
    Specifications
    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:
    265
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Dermatology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Urology
    ID:
    277
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #277: Sleep Apnea: Severity Assessment at Initial Diagnosis

    Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

    Measure Type
    • Process
    Specifications
    Specialty
    • Internal Medicine
    • Neurology
    • Otolaryngology
    • Pulmonology
    ID:
    279
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

    Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured

    Measure Type
    • Process
    Specifications
    Specialty
    • Internal Medicine
    • Neurology
    • Otolaryngology
    • Pulmonology
    ID:
    317
    NQF:
    eMeasure ID:
    CMS22v9
    High Priority:
    No

    2021 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
    Specifications
    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:
    318
    NQF:
    0101
    eMeasure ID:
    CMS139v9
    High Priority:
    Yes

    2021 MIPS Measure #318: Falls: Screening for Future Fall Risk

    Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Therapy/Occupational Therapy
    • Podiatry
    ID:
    331
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:
    332
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:
    357
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #357: Surgical Site Infection (SSI)

    Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Surgery
    • Otolaryngology
    • Plastic Surgery
    • Vascular Surgery
    ID:
    358
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • General Surgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    374
    NQF:
    eMeasure ID:
    CMS50v9
    High Priority:
    Yes

    2021 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
    Specifications
    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:
    398
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #398: Optimal Asthma Control

    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

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Pulmonology
    ID:
    402
    NQF:
    2803
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #402: Tobacco Use and Help with Quitting Among Adolescents

    The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urgent Care
    • Vascular Surgery
    ID:
    431
    NQF:
    2152
    eMeasure ID:
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • 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:
    464
    NQF:
    0657
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #464: Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use

    Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    • *These measures represent the Otolaryngology Specialty Measures Set.
  2. 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.
  3. 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:

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