- 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:047NQF:0326eMeasure 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
SpecificationsSpecialty- 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:048NQF:eMeasure ID:High Priority:No2022 MIPS Measure #048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- Urology
ID:050NQF:eMeasure ID:High Priority:Yes2022 MIPS Measure #050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Physical Therapy/Occupational Therapy
- Urology
ID:102NQF:0389eMeasure ID:CMS129v11High Priority:Yes2022 MIPS Measure #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer
Measure Type- Process
Specialty- Oncology/Hematology
- Radiation Oncology
- Urology
ID:104NQF:0390eMeasure ID:High Priority:No2022 MIPS Measure #104: Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate.
Measure Type- Process
SpecificationsSpecialty- Urology
ID:119NQF:0062eMeasure ID:CMS134v10High Priority:No2022 MIPS Measure #119: Diabetes: Medical Attention for Nephropathy
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Measure Type- Process
Specialty- Endocrinology
- Family Medicine
- Internal Medicine
- Nephrology
- Preventive Medicine
- Urology
ID:128NQF:eMeasure ID:CMS69v10High Priority:No2022 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.
Measure Type- Process
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nutrition/Dietician
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
- Vascular Surgery
ID:130NQF:eMeasure ID:CMS68v11High Priority:Yes2022 MIPS Measure #130: Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
Measure Type- Process
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- 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:226NQF:0028eMeasure ID:CMS138v10High Priority:No2022 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
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:265NQF:eMeasure ID:High Priority:Yes2022 MIPS Measure #265: Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.
Measure Type- Process
SpecificationsSpecialty- Dermatology
- Obstetrics/Gynecology
- Otolaryngology
- Urology
ID:317NQF:eMeasure ID:CMS22v10High Priority:No2022 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
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:358NQF:eMeasure ID:High Priority:Yes2022 MIPS Measure #358: Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
Measure Type- Process
SpecificationsSpecialty- General Surgery
- Orthopedic Surgery
- Otolaryngology
- Plastic Surgery
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:374NQF:eMeasure ID:CMS50v10High Priority:Yes2022 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Interventional Radiology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:431NQF:2152eMeasure ID:High Priority:No2022 MIPS Measure #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user
Measure Type- Process
SpecificationsSpecialty- Cardiology
- 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:432NQF:eMeasure ID:High Priority:Yes2022 MIPS Measure #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:433NQF:eMeasure ID:High Priority:Yes2022 MIPS Measure #433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:462NQF:eMeasure ID:CMS645v5High Priority:No2022 MIPS Measure #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.
Measure Type- Process
SpecificationsSpecialty- Endocrinology
- Oncology/Hematology
- Urology
ID:476NQF:eMeasure ID:CMS771v3High Priority:Yes2022 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.
Measure Type- Outcome
SpecificationsSpecialty- Geriatrics
- Urology
ID:481NQF:eMeasure ID:CMS646v2High Priority:Yes2022 MIPS Measure #481: Intravesical Bacillus-Calmette-Guerin for Non-muscle Invasive Bladder Cancer
Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.
Measure Type- Process
SpecificationsSpecialty- Urology
- PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 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.
- e-Prescribing
- Query of Prescription Drug Monitoring Program (PDMP) (optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops by Sending Health Information
- Support Electronic Referral Loops by Receiving and Reconciling Health Information
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- IA: Improvement Activities - 15% of total score: Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year. There are over 100 possible activities to choose from. The following are suggestions for your specialty:
- IA_EPA_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_AHE_1 - Enhance Engagement of Medicaid and Other Underserved Populations (high weighted).
- IA_BE_14 - Engage patients and families to guide improvement in the system of care (high weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- Full list of Improvement Activities