2018 MIPS Quality Measures

All 2018 MIPS registry quality measures can be reported with MDinteractive.  

Each provider will need to submit data on at >= 60% of applicable Medicare and non-Medicare patients on at least 6 quality measures for the entire year.

To report measures via registry, please create an account with MDinteractive.  There is no upfront fee associated with creating an account.

You will need to contact MDinteractive (800.634.4731 or support@mdinteractive.com) if one of the available 2018 registry measures is missing in your account. 

Please check 2018 Measure Specifications for Claims and Registry Release Notes to see changes to existing measures made since the release of the 2017 MIPS Measure Specifications. Please use the Code Master file, if you are looking for the individual MIPS measures that apply to the specific ICD10 and/or CPT codes that you use to bill Medicare. You also can get additional information about the quality measures: 

#1. Diabetes: Hemoglobin A1c Poor Control Outcome

Measure Description pdf.png (CMS)

#5. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure Description pdf.png (CMS)

#6. Coronary Artery Disease (CAD): Antiplatelet Therapy

Measure Description pdf.png (CMS)

#7. Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)

Measure Description pdf.png (CMS)

#8. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure Description pdf.png (CMS)

#12. Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

Measure Description pdf.png (CMS)

#14. Age-Related Macular Degeneration (AMD): Dilated Macular Examination

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#19. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care High Priority

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#21. Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin High Priority

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#23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) High Priority

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#24. Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older High Priority

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#39. Screening for Osteoporosis for Women Aged 65-85 Years of Age

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#43. Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

Measure Description pdf.png (CMS)

#44. Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery

Measure Description pdf.png (CMS)

#46. Medication Reconciliation Post-Discharge High Priority

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#47. Care Plan High Priority

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#48. Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Measure Description pdf.png (CMS)

#50. Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older High Priority

Measure Description pdf.png (CMS)

#51. Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

Measure Description pdf.png (CMS)

#52. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy

Measure Description pdf.png (CMS)

#65. Appropriate Treatment for Children with Upper Respiratory Infection (URI) High Priority

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#66. Appropriate Testing for Children with Pharyngitis High Priority

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#67. Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow

Measure Description pdf.png (CMS)

#68. Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy

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#69. Hematology: Multiple Myeloma: Treatment with Bisphosphonates

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#70. Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry

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#76. Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections High Priority

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#91. Acute Otitis Externa (AOE): Topical Therapy High Priority

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#93. Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use High Priority

Measure Description pdf.png (CMS)

#99 . Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

Measure Description pdf.png (CMS)

#100. Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

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#102. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients High Priority

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#104. Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer

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#109. Osteoarthritis (OA): Function and Pain Assessment High Priority

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#110. Preventive Care and Screening: Influenza Immunization

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#111. Pneumonia Vaccination Status for Older Adults

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#112. Breast Cancer Screening

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#113. Colorectal Cancer Screening

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#116. Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis High Priority

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#117. Diabetes: Eye Exam

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#118. Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

Measure Description pdf.png (CMS)

#119. Diabetes: Medical Attention for Nephropathy

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#122. Adult Kidney Disease: Blood Pressure Management Outcome

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#126. Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation

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#127. Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear

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#128. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

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#130. Documentation of Current Medications in the Medical Record High Priority

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#131. Pain Assessment and Follow-Up High Priority

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#134. Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

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#137: Melanoma: Continuity of Care – Recall System High Priority

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#138: Melanoma: Coordination of Care High Priority

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#140. Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

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#141. Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Outcome

Measure Description pdf.png (CMS)

#143: Oncology: Medical and Radiation – Pain Intensity Quantified High Priority

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#144: Oncology: Medical and Radiation – Plan of Care for Pain High Priority

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#145. Exposure Time Reported for Procedures Using Fluoroscopy High Priority

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#146. Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms High Priority

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#147. Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy High Priority

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#154. Falls: Risk Assessment High Priority

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#155. Falls: Plan of Care High Priority

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#156. Oncology: Radiation Dose Limits to Normal Tissues High Priority

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#164. Coronary Artery Bypass Graft (CABG): Prolonged Intubation Outcome

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#165. Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate Outcome

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#166. Coronary Artery Bypass Graft (CABG): Stroke Outcome

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#167. Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure Outcome

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#168. Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration Outcome

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#176. Rheumatoid Arthritis (RA): Tuberculosis Screening

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#177. Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

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#178. Rheumatoid Arthritis (RA): Functional Status Assessment

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#179. Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

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#180. Rheumatoid Arthritis (RA): Glucocorticoid Management

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#181. Elder Maltreatment Screen and Follow-Up Plan High Priority

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#182. Functional Outcome Assessment High Priority

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#185. Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use High Priority

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#187. Stroke and Stroke Rehabilitation: Thrombolytic Therapy

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#191. Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Outcome

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#192. Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Outcome

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#195. Radiology: Stenosis Measurement in Carotid Imaging Reports

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#204. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Measure Description pdf.png (CMS)

#205. HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

Measure Description pdf.png (CMS)

#217. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments Outcome

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#218. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments Outcome

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#219. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments Outcome

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#220. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments Outcome

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#221. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments Outcome

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#222. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments Outcome

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#223. Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments Outcome

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#224: Melanoma: Overutilization of Imaging Studies in Melanoma High Priority

Measure Description pdf.png (CMS)

#225. Radiology: Reminder System for Screening Mammograms High Priority

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#226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

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#236. Controlling High Blood Pressure Outcome

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#238. Use of High-Risk Medications in the Elderly High Priority

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#243. Cardiac Rehabilitation Patient Referral from an Outpatient Setting High Priority

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#249. Barrett's Esophagus

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#250. Radical Prostatectomy Pathology Reporting

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#251. Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients

Measure Description pdf.png (CMS)

#254. Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

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#255. Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

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#257. Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

Measure Description pdf.png (CMS)

#258. Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) Outcome

Measure Description pdf.png (CMS)

#259. Rate of Elective Endovascular Aortic Repair (EVAR) of Small or Moderate Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) Outcome

Measure Description pdf.png (CMS)

#260. Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome

Measure Description pdf.png (CMS)

#261. Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness High Priority

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#262. Image Confirmation of Successful Excision of Image-Localized Breast Lesion High Priority

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#263. Preoperative Diagnosis of Breast Cancer

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#264. Sentinel Lymph Node Biopsy for Invasive Breast Cancer

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#265: Biopsy Follow-Up High Priority

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#268. Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

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#271. Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury

Measure Description pdf.png (CMS)

#275. Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

Measure Description pdf.png (CMS)

#276. Sleep Apnea: Assessment of Sleep Symptoms

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#277. Sleep Apnea: Severity Assessment at Initial Diagnosis

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#278. Sleep Apnea: Positive Airway Pressure Therapy Prescribed

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#279. Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

Measure Description pdf.png (CMS)

#282. Dementia: Functional Status Assessment

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#283. Dementia: Neuropsychiatric Symptom Assessment

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#286. Dementia: Counseling Regarding Safety Concerns High Priority

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#288. Dementia: Caregiver Education and Support High Priority

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#290. Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease

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#291. Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment

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#293. Parkinson’s Disease: Rehabilitative Therapy Options High Priority

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#303. Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery Outcome

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#304. Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery Outcome

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#317. Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

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#320. Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients High Priority

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#322. Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients High Priority

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#323. Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) High Priority

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#324. Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients High Priority

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#325. Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions High Priority

Measure Description pdf.png (CMS)

 #326. Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

Measure Description pdf.png (CMS)

#327. Pediatric Kidney Disease: Adequacy of Volume Management High Priority

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#328. Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL Outcome

Measure Description pdf.png (CMS)

#329. Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis Outcome

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#330. Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days Outcome

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#331. Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) High Priority

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#332. Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) High Priority

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#333. Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) High Priority

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 #334. Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) High Priority

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 #335. Maternity Care: Elective Delivery or Early Induction Without Medical Indication at = 37 and < 39 Weeks (Overuse) Outcome

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 #336. Maternity Care: Post-Partum Follow-Up and Care Coordination High Priority

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 #337. Tuberculosis Prevention for Psoriasis,Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier

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 #338. HIV Viral Load Suppression Outcome

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 #340. HIV Medical Visit Frequency High Priority

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 #342. Pain Brought Under Control Within 48 Hours Outcome

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 #343. Screening Colonoscopy Adenoma Detection Rate Outcome

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 #344. Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome

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 #345. Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS): Outcome

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#346. Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Outcome

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#347. Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital Outcome

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#348. HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate Outcome

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#350. Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy High Priority

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#351. Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation High Priority

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#352. Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet High Priority

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#353. Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report High Priority

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#354. Anastomotic Leak Intervention Outcome

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#355. Unplanned Reoperation within the 30 Day Postoperative Period Outcome

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#356. Unplanned Hospital Readmission within 30 Days of Principal Procedure Outcome

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#357. Surgical Site Infection (SSI) Outcome

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#358. Patient-centered Surgical Risk Assessment and Communication High Priority

Measure Description (CMS) 

#359. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description High Priority

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#360.Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies High Priority

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#361. Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry High Priority

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#362. Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes High Priority

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#363. Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive High Priority

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#364. Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines High Priority

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#370. Depression Remission at Twelve Months Outcome

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#374. Closing the Referral Loop: Receipt of Specialist Report High Priority

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#383. Adherence to Antipsychotic Medications For Individuals with Schizophrenia Outcome

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#384. Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery Outcome

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#385. Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Outcome

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#386. Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Outcome

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#387. Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

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#388. Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) Outcome

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#389. Cataract Surgery: Difference Between Planned and Final Refraction Outcome

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#390. Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options High Priority

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#391. Follow-Up After Hospitalization for Mental Illness (FUH) High Priority

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#392. HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation Outcome

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#393. HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Outcome

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#394.  Immunizations for Adolescents

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#395. Lung Cancer Reporting (Biopsy/Cytology Specimens) Outcome

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#396. Lung Cancer Reporting (Resection Specimens)  Outcome

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#397. Melanoma Reporting Outcome

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#398. Optimal Asthma Control  Outcome

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#400. One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

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#401. Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

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#402.Tobacco Use and Help with Quitting Among Adolescents 

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#403: Adult Kidney Disease: Referral to Hospice High Priority

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#404: Anesthesiology Smoking Abstinence Outcome

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#405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions High Priority

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#406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients High Priority

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#407: Appropriate Treatment of MSSA Bacteremia High Priority

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#408: Opioid Therapy Follow-up Evaluation

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#409: Clinical Outcome Post Endovascular Stroke Treatment Outcome

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#410: Psoriasis: Clinical Response to Oral Systemic or Biologic Medications Outcome

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#411: Depression Remission at Six Months  Outcome

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#412: Documentation of Signed Opioid Treatment Agreement 

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#413: Door to Puncture Time for Endovascular Stroke Treatment Outcome

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#414: Evaluation or Interview for Risk of Opioid Misuse

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#415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older High Priority

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#416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years High Priority

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#417: Rate of Open Repair of Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive Outcome

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#418: Osteoporosis Management in Women Who Had a Fracture

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#419: Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination High Priority

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#420: Varicose Vein Treatment with Saphenous Ablation: Outcome Survey - Outcome

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#421: Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal

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#422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury High Priority

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#423: Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy

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#424. Perioperative temperature management Outcome

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#425: Photodocumentation of Cecal Intubation

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#426: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) High Priority

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#427: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) High Priority

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#428: Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

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#429: Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy High Priority

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#430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy High Priority

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#431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

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#432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair  Outcome

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#433: Proportion of Patients Sustaining a Major Viscus Injury at the time of any Pelvic Organ Prolapse Repair  Outcome

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#434: Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair Outcome

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#435: Quality of Life Assessment For Patients With Primary Headache Disorders  Outcome

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#436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques 

Measure Description pdf.png (CMS)

#437: Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure Outcome

Measure Description pdf.png (CMS)

#438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 

Measure Description pdf.png (CMS)

#439: Age Appropriate Screening Colonoscopy  High Priority

Measure Description pdf.png (CMS)

#440: Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician  High Priority

Measure Description pdf.png (CMS)

#441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)  Outcome

Measure Description pdf.png (CMS)

#442: Persistence of Beta-Blocker Treatment After a Heart Attack 

Measure Description pdf.png (CMS)

#443: Non-Recommended Cervical Cancer Screening in Adolescent Females  High Priority

Measure Description pdf.png (CMS)

#444: Medication Management for People with Asthma  High Priority

Measure Description pdf.png (CMS)

#445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)  Outcome

Measure Description pdf.png (CMS)

#446: Operative Mortality Stratified by the Five STS-EACTS Mortality Categories  Outcome

Measure Description pdf.png (CMS)

#447: Chlamydia Screening and Follow Up 

Measure Description pdf.png (CMS)

#448: Appropriate Workup Prior to Endometrial Ablation  High Priority

Measure Description pdf.png (CMS)

#449: HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies  High Priority

Measure Description pdf.png (CMS)

#450: Trastuzumab Received By Patients With AJCC Stage I (T1c)–III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy  High Priority

Measure Description pdf.png (CMS)

#451: KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy 

Measure Description pdf.png (CMS)

#452: Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies  High Priority

Measure Description pdf.png (CMS)

#453: Proportion Receiving Chemotherapy in the Last 14 Days of Life  High Priority

Measure Description pdf.png (CMS)

#454: Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life 

Measure Description pdf.png (CMS)

#455: Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life  Outcome

Measure Description pdf.png (CMS)

#456: Proportion Not Admitted To Hospice  High Priority

Measure Description pdf.png (CMS)

#457: Proportion Admitted to Hospice for less than 3 days  Outcome

Measure Description pdf.png (CMS)

#459: Average Change in Back Pain following Lumbar Discectomy / Laminotomy  Outcome

Measure Description pdf.png (CMS)

#460: Average Change in Back Pain following Lumbar Fusion  Outcome

Measure Description pdf.png (CMS)

#461: Average Change in Leg Pain following Lumbar Discectomy / Laminotomy Outcome

Measure Description pdf.png (CMS)

#463: Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)

Measure Description pdf.png (CMS)

#464: Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use

Measure Description pdf.png (CMS)

#465: Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

Measure Description pdf.png (CMS)

#467: Developmental Screening in the First Three Years of Life

Measure Description pdf.png (CMS)


How to choose MIPS quality measures

  • The following factors could be considered when deciding which measures to select for MIPS reporting:
    • Clinical conditions usually treated;
    • Types of care typically provided (e.g., preventive, chronic, acute);
    • Settings where care is usually delivered (e.g., office, emergency department [ED], surgical suite);
    • Quality improvement goals;
    • Other quality reporting programs in use or being considered;
       
  • Find out if any of the MIPS quality specialty sets apply to your specialty. You can find our suggestions by specialty here.
  • Because you will need to report at least 60% of the patients/visits eligible for a measure (ALL insurances, Medicare and not Medicare) you could select measures with a more defined demographic in order to create a manageable size report. 
  • There are several advantages of reporting MIPS at the group level instead of individual level:
    • Let's imagine a practice with one anesthesiologist, one pathologist, one hospitalist, one internist, one dermatologist and one cardiologist. If the providers report MIPS at the individual level, one potentially would need to manage and optimize the performance of  36 different quality measures. At the group level, one could report just the 6 best measures. The combination could be 2 anesthesia measures, 2 pathology measures and 2 hospitalist measures. There is no need to cover all specialties. One just needs to report the patients/visits eligible for the chosen measures. For example, measure #137 (Melanoma: Continuity of Care – Recall System) will only apply for patients seen by the dermatologist. Please note that there are measures that apply to patients seen by different specialties: for example measure #226  (Tobacco Use: Screening and Cessation Intervention) will apply to all outpatient office visits done by the internists, dermatologists and cardiologists. 
    • The same group level reporting advantages would apply with other MIPS components like Improvement Activities. For example, all 6 members of the practice described above could share on the MIPS points when just one  cardiologist is participating in the systematic anticoagulation program (high weighted Improvement Activity).
    • ACI: Satisfy the mandatory base score measures as a group. Base score measures are mandatory for ACI. If you participate in MIPS as an individual, your ACI score will be 0% unless you successfully meet the requirements of all the base score measures. But when you participate as part of a group, if another provider in your group fulfills a base score measure, then everybody in the group is considered to have fulfilled that measure.
  • It can be easier to report more specific measures that apply to smaller patient populations. For example, dermatologists could report melanoma measures #137, #138 and #224. However, one needs to report a minimum of 20 patients in order to get a score higher than 3.
  • Please note the reporting frequency of measures like measure #226 (Tobacco Use: Screening and Cessation Intervention) that only need to be reported once per patient per year versus measures like measure #130 (Documentation of Current Medications in the Medical Record) that need to be reported on each eligible visit. For example, measure #226 only needs to be reported once on a patient seen for a total of 7 times by 4 different providers at the group level. Measure #130 will need to be reported 7 times on this case.
  • Be aware of "easy" measures with which most providers already have high compliance (i.e. high national benchmarks). Medicare calls these measures "topped-out" measures. For example, measure #130 (Documentation of Current Medication in the Medical Record) has the following MIPS scoring:
    • 3 Points 61.27 - 82.11 %
    • 4 Points 82.12 - 91.71 %   - This means that a provider with a performance rate of 90% will only get 4 MIPS points
    • 5 Points 91.72 - 96.86 %   
    • 6 Points 96.87 - 99.30 %
    • 7 Points 99.31 - 99.99 %
    • 10 Points 100 % - This means that if a provider only gets 10 points on this measure if ALL patients had medications documented on ALL visits. If the documentation is not done once during the reporting period, the provider will get 7 points or less instead of 10.
  • Be aware of choosing measures without benchmarks. Measures without benchmarks can only earn maximum 3 points (unless the measure is a high priority or outcome measure where one could could get one or two additional bonus points).
  • You can find the MIPS quality measures benchmarks and which measures have no benchmarks or are topped-out on this CMS Excel file.
  • Example of MIPS quality measures which give 10 points with performances below 100%:
    • #400 Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk >= 20.02%
    • #343 Screening Colonoscopy Adenoma Detection Rate >= 80.33%
    • #39 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older >= 82.54%
    • #112 Breast Cancer Screening  >= 87.93%
    • #113 Colorectal Cancer Screening >= 88.15%
    • #111 Pneumonia Vaccination Status for Older Adults >= 90.20%
    • #236 Controlling High Blood Pressure >= 91.07%
    • #110 Preventive Care and Screening: Influenza Immunization >= 91.84%
    • #118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) >= 96.00%
    • #5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) >= 96.55%
    • #128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan >= 97.34%
    • #7 Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) >= 97.92%
    • #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented >= 98.88%
    • #119 Diabetes: Medical Attention for Nephropathy >= 99.71%
    • #178 Rheumatoid Arthritis (RA): Functional Status Assessment >= 99.72%
    • #122 Adult Kidney Disease: Blood Pressure Management >= 99.75%
  • Example of inverse MIPS quality measures which give 10 points with performances higher than 0%:
    • #1 Diabetes: Hemoglobin A1c Poor Control <= 10.32%>
    • #164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation <=  1.82%
  • Examples of measures that are not topped-out and have benchmarks that could be reported by an internist:
    • Measure #1 (Diabetes A1C) - High Priority Measure

      • 3 Points 83.10 - 68.19 %
      • 4 Points 68.18 - 53.14 %
      • 5 Points 53.13 - 40.66 %
      • 6 Points 40.65 - 30.20 %
      • 7 Points 30.19 - 22.74 %  - For example, 30% performance will get the provider 7 points. Please note this is an inverse measure.
      • 8 Points 22.73 - 16.82 %
      • 9 Points 16.81 - 10.33 %
      • 10 Points <= 10.32 %
    • Measure #48 Urinary Incontinence

      • 3 Points 16.31 - 29.03 %
      • 4 Points 29.04 - 42.90 %
      • 5 Points 42.91 - 57.07 %
      • 6 Points 57.08 - 76.52 %
      • 7 Points 76.53 - 89.12 % -  For example, 77% performance will get the provider 7 points.
      • 8 Points 89.13 - 96.91 %
      • 9 Points 96.92 - 99.99 %
      • 10 Points 100 %
    • Measure #112 Breast Cancer Screening

      • 3 Points 14.49 - 24.52 %
      • 4 Points 24.53 - 35.70 %
      • 5 Points 35.71 - 46.01 %
      • 6 Points 46.02 - 55.06 %
      • 7 Points 55.07 - 63.67 % -  For example, 56% performance will get the provider 7 points.
      • 8 Points 63.68 - 74.06 %
      • 9 Points 74.07 - 87.92 %
      • 10 Points 87.93 % -  For example, 88% performance will get the provider 10 points.
    • Measure #236 Controlling High Blood Pressure - Outcome Measure

      • 3 Points 51.00 -58.20 %
      • 4 Points 58.21 - 63.56 %
      • 5 Points 63.57 - 68.27 %
      • 6 Points 68.28 - 72.40 %
      • 7 Points 72.41 - 76.69 % -  For example, 73% performance will get the provider 7 points.
      • 8 Points 76.70 - 82.75 %
      • 9 Points 82.76 - 91.06 %
      • 10 Points 91.07%
  • Examples of measures that are not topped-out and have benchmarks that could be reported by a cardiologist:
    1. Measure# 5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

          • 3 Points 75.86 - 79.58%
          • 4 Points 79.49 - 82.13 %
          • 5 Points 82.14 - 84.99 %
          • 6 Points 85.00-87.49 %
          • 7 Points 87.50 - 89.99 %  - For example, 88% performance will get the provider 7 points.
          • 8 Points 90.00 - 93.53%
          • 9 Points 93.54 - 96.54 %
          • 10 Points 96.55 %
        • Measure #8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Add

          • 3 Points 76.58 - 81.07 %
          • 4 Points 81.08 - 85.57 %
          • 5 Points 85.58 - 88.43 %
          • 6 Points 88.44 - 91.16 %
          • 7 Points 91.17 - 94.28 % -  For example, 92% performance will get the provider 7 points.
          • 8 Points 94.29 - 96..36 %
          • 9 Points 96.37 - 99.99 %
          • 10 Points 100 %
        • 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%)

          • 3 Points 71.03 - 74.18 %
          • 4 Points 74.19 - 76.51 %
          • 5 Points 76.52 - 78.94 %
          • 6 Points 78.95 - 81.10%
          • 7 Points 81.11 - 83.99 % -  For example, 82% performance will get the provider 7 points.
          • 8 Points 84.00 - 87.79 %
          • 9 Points 8780 - 95.99 %
          • 10 Points 96.00 %
        • Measure #326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

          • 3 Points 20.00 - 30.18%
          • 4 Points 39.19 - 52.33 %
          • 5 Points 52.34 - 69.56 %
          • 6 Points 69.57 - 76.18 %
          • 7 Points 76.19 - 82.49 % -  For example, 77% performance will get the provider 7 points.
          • 8 Points 82.50 - 94.33 %
          • 9 Points 94.34 - 99.99
          • 10 Points 100.00%
  • Examples of measures that are not topped-out and have benchmarks that could be reported by an allergist/immunologist:
  • Measure# 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    • 3 Points 24.74 - 35.47%
    • 4 Points 35.48 - 47.87%
    • 5 Points 47.88 - 62.14%
    • 6 Points 62.15 - 71.64%
    • 7 Points 71.65-79.36 %  - For example, 72% performance will get the provider 7 points.
    • 8 Points 79.37 - 88.85%
    • 9 Points 88.86 - 98.87%
    • 10 Points 96.55 %
  • Measure #331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Inverse Measure High Priority Measure

    • 3 Points 89.07 - 82.41%
    • 4 Points 82.40 - 71.44 %
    • 5 Points 71.43 - 46.46 %
    • 6 Points 46.45 - 16.91 %
    • 7 Points 16.90 - 0.60 % -  For example, 16% performance will get the provider 7 points.
    • 8 Points 0.59 - 0.01%
    • 9 Points n/a
    • 10 Points 0%
  • Measure #332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) High Priority Measure

    • 3 Points 44.39 - 47.99 %
    • 4 Points 48.00 - 51.88 %
    • 5 Points 51.89 - 57.57%
    • 6 Points 57.58 - 64.99%
    • 7 Points 65.00 - 72.72% -  For example, 65% performance will get the provider 7 points.
    • 8 Points 72.73 - 95.99 %
    • 9 Points 96.00 - 99.99 %
    • 10 Points 100%
  • Measure #402 Tobacco Use and Help with Quitting Among Adolescents

    • 3 Points 74.10 - 82.15 %
    • 4 Points 81.16 - 87.49 %
    • 5 Points 87.50 - 90.37%
    • 6 Points 90.38 - 92.72 %
    • 7 Points 92.73 - 95.15 % -  For example, 93% performance will get the provider 7 points.
    • 8 Points 95.16 - 97.50 %
    • 9 Points 97.51 - 99.99
    • 10 Points 100%
  1. Examples of measures that are not topped-out and have benchmarks that could be reported by an rheumatologist:
  • Measure# 47 Care Plan - High Priority Measure

    • 3 Points 16.52 - 38.11%
    • 4 Points 38.12 - 59.14%
    • 5 Points 59.15 - 74.99%
    • 6 Points 75.00 - 88.71%
    • 7 Points 88.72 - 96.29 %  - For example, an 89% performance will get the provider 7 points.
    • 8 Points 96.30 - 99.17%
    • 9 Points 99.18 - 99.99%
    • 10 Points 100%
  • Measure #178 Rheumatoid Arthritis (RA): Functional Status Assessment

    • 3 Points 27.99 - 45.95%
    • 4 Points 45.96 - 64.17 %
    • 5 Points 64.18 - 74.46 %
    • 6 Points 7.47 - 81.36 %
    • 7 Points 81.37 - 87.82% -  For example, 82% performance will get the provider 7 points.
    • 8 Points 87.83 - 92.34%
    • 9 Points 92.35 - 99.71
    • 10 Points 100%
  • Measure #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    • 3 Points 24.74 - 35.47 %
    • 4 Points 35.48 - 47.87 %
    • 5 Points 47.88 - 62.14%
    • 6 Points 62.15 - 71.64%
    • 7 Points 71.65 - 79.36% -  For example, 72% performance will get the provider 7 points.
    • 8 Points 79.37 - 88.85 %
    • 9 Points 88.86 - 98.87 %
    • 10 Points 98.88%

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