2022 MIPS Measures Relevant to Obstetrics and Gynecology

  1. Quality - 30% 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 receive a score against 2022 National Benchmarks. Suggestions for your specialty include, but are not limited to, the following:

     

    ID:
    047
    NQF:
    0326
    eMeasure ID:
    High Priority:
    Yes

    2022 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
    • Certified Nurse Midwife
    • Clinical Social Work
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Internal Medicine
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    048
    NQF:
    eMeasure ID:
    High Priority:
    No

    2022 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
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • Urology
    ID:
    050
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 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
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Physical Therapy/Occupational Therapy
    • Urology
    ID:
    110
    NQF:
    0041
    eMeasure ID:
    CMS147v11
    High Priority:
    No

    2022 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
    • Certified Nurse Midwife
    • 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:
    CMS127v10
    High Priority:
    No

    2022 MIPS Measure #111: Pneumococcal Vaccination Status for Older Adults

    Percentage of patients 66 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
    • Nephrology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Otolaryngology
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    112
    NQF:
    2372
    eMeasure ID:
    CMS125v10
    High Priority:
    No

    2022 MIPS Measure #112: Breast Cancer Screening

    Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    ID:
    128
    NQF:
    eMeasure ID:
    CMS69v10
    High Priority:
    No

    2022 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
    • Plastic Surgery
    • Podiatry
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Urology
    • Vascular Surgery
    ID:
    130
    NQF:
    eMeasure ID:
    CMS68v11
    High Priority:
    Yes

    2022 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
    • Certified Nurse Midwife
    • 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:
    226
    NQF:
    0028
    eMeasure ID:
    CMS138v10
    High Priority:
    No

    2022 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 the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Certified Nurse Midwife
    • 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:
    236
    NQF:
    eMeasure ID:
    CMS165v10
    High Priority:
    Yes

    2022 MIPS Measure #236: Controlling High Blood Pressure

    Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Pulmonology
    • Rheumatology
    • Vascular Surgery
    ID:
    265
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 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:
    309
    NQF:
    eMeasure ID:
    CMS124v10
    High Priority:
    No

    2022 MIPS Measure #309: Cervical Cancer Screening

    Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

    * Women age 21-64 who had cervical cytology performed within the last 3 years
    * Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:
    310
    NQF:
    eMeasure ID:
    CMS153v10
    High Priority:
    No

    2022 MIPS Measure #310: Chlamydia Screening for Women

    Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Pediatrics
    ID:
    317
    NQF:
    eMeasure ID:
    CMS22v10
    High Priority:
    No

    2022 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 elevated 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
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    335
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 MIPS Measure #335: Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)

    Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Certified Nurse Midwife
    • Obstetrics/Gynecology
    ID:
    336
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 MIPS Measure #336: Maternity Care: Postpartum Follow-Up and Care Coordination

    Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update

    Measure Type
    • Process
    Specifications
    Specialty
    • Certified Nurse Midwife
    • Obstetrics/Gynecology
    ID:
    374
    NQF:
    eMeasure ID:
    CMS50v10
    High Priority:
    Yes

    2022 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
    • Neurology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    402
    NQF:
    2803
    eMeasure ID:
    High Priority:
    No

    2022 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:
    418
    NQF:
    0053
    eMeasure ID:
    High Priority:
    No

    2022 MIPS Measure #418: Osteoporosis Management in Women Who Had a Fracture

    The percentage of women 50–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    ID:
    422
    NQF:
    2063
    eMeasure ID:
    High Priority:
    Yes

    2022 MIPS Measure #422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

    Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

    Measure Type
    • Process
    Specifications
    Specialty
    • Obstetrics/Gynecology
    ID:
    431
    NQF:
    2152
    eMeasure ID:
    High Priority:
    No

    2022 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
    • Certified Nurse Midwife
    • 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:
    432
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:
    433
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:
    443
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2022 MIPS Measure #443: Non-Recommended Cervical Cancer Screening in Adolescent Females

    The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:
    448
    NQF:
    0567
    eMeasure ID:
    High Priority:
    Yes

    2022 MIPS Measure #448: Appropriate Workup Prior to Endometrial Ablation

    Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.

    Measure Type
    • Process
    Specifications
    Specialty
    • Obstetrics/Gynecology
    ID:
    472
    NQF:
    eMeasure ID:
    CMS249v4
    High Priority:
    Yes

    2022 MIPS Measure #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

    Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:
    475
    NQF:
    eMeasure ID:
    CMS349v4
    High Priority:
    No

    2022 MIPS Measure #475: HIV Screening

    Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.

    Measure Type
    • Process
    Specifications
    Specialty
    • Certified Nurse Midwife
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • *These measures represent the Obstetrics/Gynecology 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, 2022. 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 55% 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.  The following are suggestions for your specialty:

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