2023 MIPS Quality Measures

All 2023 CMS MIPS registry and EHR quality measures can be reported with MDinteractive.  Please check 2023 Clinical Quality Measure (CQM) Release Notes to see changes to existing measures made since the release of the 2022 MIPS Measure Specifications. 

Choose and report 6 measures, including one Outcome or other High Priority measure for the full calendar year on at least 70% of eligible encounters*, regardless of insurance. 

*eligible encounters are those, where the claim generated for the date of service, matches the denominator criteria as outlined in the documentation for the measure.

Tips for choosing MIPS quality measures

  • Start by reviewing the suggestions by specialty available on our website.  Note that CMS has identified “Specialty Measures Sets” for the majority of specialties. Suggestions for your specialty can be found here.  
  • You can access our MIPS planning tool within our software by logging into your account, setting up your dashboard with NPI/TIN and clicking on Add/Edit MIPS Plans. After you indicate the categories you will be reporting and clicking “Next”, you will be able to choose from a list of applicable measures or use the filters to narrow down your choices. Note that only measures where you have claims history matching the criteria will appear in this list.  Please contact MDinteractive if you don’t see a measure available on your list.
  • Consider the following factors 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;
    • Only choosing/reporting measures where you have eligible encounters, meaning encounters where the coding on the claims matches the denominator criteria for the measure.  The documentation for all measures can be found on this link: 2022 Quality Measures.
  • At least 1 of the measures you choose (out of a total of 6) must be designated as either Outcome, or if no applicable Outcome, another High Priority measure.  If a measure with either of these designations is not included in your reporting, CMS will only score 5 out of your 6 measures. The following is an explanation of the measure “types”:
    • Process - Process measures show what doctors and other clinicians do to maintain or improve health, either for healthy people or those diagnosed with a given condition or disease.  These measures usually reflect generally accepted recommendations for clinical practice.  Process measures can tell consumers about medical care they should receive for a given condition or disease, and can help improve health outcomes.
    • Outcome - Outcome measures show how a health care service or intervention influences the health status of patients. Examples: The % of patients who died because of surgery or the rate of surgical complications or hospital acquired infections.  Outcome measures are the result of many factors, some of which may be out of a clinician's control. An Outcome Measure is also classified as High Priority.  CMS asks for an Outcome Measure to be reported as part of the 6 total measures (if one is applicable).
    • High Priority - High priority measures include the following categories of measures:  Outcome, Appropriate Use, Patient Experience, Patient Safety, Efficiency measures, Care coordination. If an Outcome measure (see above) is not applicable, a measure designated as just “high priority” will suffice. 
  • Because you will need to report at least 70% of the patients/visits eligible for a measure (ALL insurances, Medicare and not Medicare) you could choose to select measure(s) with a more defined demographic (meaning that the denominator criteria is limited by ICD-10, age, gender, etc. vs. all eligible patient visits) in order to create a manageable size report.  Note though that measures must be complete and contain at least 20 denominator eligible cases in order to be scored against national benchmarks.
  • Choosing to report Quality measures as a group (if more than two in the practice) might be a more efficient way to report.  Here is an example of how this would work:
    • Multi-specialty practice: 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 (6 measures per provider). A group would be able to choose 6 measures that would “cover” the entire practice.   For example, the measure selection could include 2 anesthesia measures, 2 pathology measures and 2 hospitalist measures. There is no need to choose measures that 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. 
  • It can be easier to report more specific measures that apply to smaller patient populations. For example, dermatologists could report melanoma measures #137 and #138. However, one needs to report a minimum of 20 patients in order to get a score higher than 3.
  • Consider the reporting frequency of measures such as 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 eligible encounters. Measure #130 will need to be reported 7 times in this example.

Understanding Benchmarks*/Scoring when Choosing Your Quality Measures:

  • Be aware of measures which already have high compliance. Medicare calls these "topped-out" measures. For example, Measure #130 (Documentation of Current Medication in the Medical Record) has the following MIPS scoring. Note that a performance score of 100% will only achieve 7 (vs. 10) MIPS points. MIPS 2021 benchmarks for all measures can be found here 
    • 3 Points 3.07 - 43.67 %
    • 4 Points 43.68 - 94.64 %  
    • 5 Points 94.65 - 99.68 %   
    • 6 Points 99.69 - 99.99 %
    • 7 Points 100%
  • Take into consideration that some measures do not currently have benchmarks. As a result, these measures will initially achieve only 3 points - even if reported completely. 
  • You can find the MIPS quality measures benchmarks and which measures have no benchmarks or are topped-out here: 2021 Quality Benchmarks. *2022 Benchmarks will be published shortly.
  • The following is a list of measures, within a selection of specialties, that can achieve at least 8 points for less than 100% performance or 0% performance for inverse measures (*denotes a measure that can only be reported if data calculated by EHR):
    • Internal Medicine 
      • Measure 1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
      • Measure 39 Screening for Osteoporosis for Women Aged 65-85 Years of Age
      • Measure 111 Pneumococcal Vaccination Status for Older Adults
      • Measure 236 Controlling High Blood Pressure
      • Measure 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting
      • Measure 305* Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
      • Measure 309* Cervical Cancer Screening
      • Measure 318* Falls: Screening for Future Fall Risk
      • Measure 331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
      • Measure 377* Functional Status Assessments for Congestive Heart Failure
      • Measure 400 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
      • Measure 418 Osteoporosis Management in Women Who Had a Fracture
      • Measure 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
    • Cardiology
      • 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%)
      • Measure 236 Controlling High Blood Pressure
      • Measure 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting
      • Measure 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
    • Allergist/Immunology
      • Measure 111 Pneumococcal Vaccination Status for Older Adults
    • Rheumatology
      • Measure 39 Screening for Osteoporosis for Women Aged 65-85 Years of Age
      • Measure 111 Pneumococcal Vaccination Status for Older Adults
      • Measure 236 Controlling High Blood Pressure
ID:
001
NQF:
0059
eMeasure ID:
CMS122v11
High Priority:
Yes

2023 MIPS Measure #001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Endocrinology
  • Family Medicine
  • Internal Medicine
  • Nephrology
  • Nutrition/Dietician
  • Preventive Medicine
ID:
005
NQF:
0081
eMeasure ID:
CMS135v1
High Priority:
No

2023 MIPS Measure #005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Hospitalists
  • Internal Medicine
ID:
006
NQF:
0067
eMeasure ID:
High Priority:
No

2023 MIPS Measure #006: Coronary Artery Disease (CAD): Antiplatelet Therapy

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Skilled Nursing Facility
ID:
007
NQF:
0070
eMeasure ID:
CMS145v11
High Priority:
No

2023 MIPS Measure #007: Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker therapy.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Skilled Nursing Facility
ID:
008
NQF:
0083
eMeasure ID:
CMS144v101
High Priority:
No

2023 MIPS Measure #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Hospitalists
  • Internal Medicine
  • Skilled Nursing Facility
ID:
009
NQF:
eMeasure ID:
CMS128v11
High Priority:
No

2023 MIPS Measure #009: Anti-Depressant Medication Management

Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported.

  1. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).
  2. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:
012
NQF:
0086
eMeasure ID:
CMS143v11
High Priority:
No

2023 MIPS Measure #012: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:
014
NQF:
0087
eMeasure ID:
High Priority:
No

2023 MIPS Measure #014: Age-Related Macular Degeneration (AMD): Dilated Macular Examination

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:
019
NQF:
eMeasure ID:
CMS142v11
High Priority:
Yes

2023 MIPS Measure #019: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:
024
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #024: Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Orthopedic Surgery
  • Preventive Medicine
  • Rheumatology
ID:
039
NQF:
0046
eMeasure ID:
High Priority:
No

2023 MIPS Measure #039: Screening for Osteoporosis for Women Aged 65-85 Years of Age

Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.

Measure Type
  • Process
Specifications
Specialty
  • Endocrinology
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Obstetrics/Gynecology
  • Preventive Medicine
  • Rheumatology
ID:
047
NQF:
0326
eMeasure ID:
High Priority:
Yes

2023 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

2023 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
  • Physical Therapy/Occupational Therapy
  • Preventive Medicine
  • Urology
ID:
050
NQF:
eMeasure ID:
High Priority:
Yes

2023 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:
052
NQF:
0102
eMeasure ID:
High Priority:
No

2023 MIPS Measure #052: Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy

Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator.

Measure Type
  • Process
Specifications
Specialty
  • Pulmonology
ID:
065
NQF:
0069
eMeasure ID:
CMS154v11
High Priority:
Yes

2023 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 order

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Pediatrics
  • Urgent Care
ID:
066
NQF:
eMeasure ID:
CMS146v11
High Priority:
Yes

2023 MIPS Measure #066: Appropriate Testing for Pharyngitis

The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order and a group A streptococcus (strep) test in the seven-day period from three days prior to the episode date through three days after the episode date

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

2023 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:
102
NQF:
0389
eMeasure ID:
CMS129v12
High Priority:
Yes

2023 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
Specifications
Specialty
  • Oncology/Hematology
  • Radiation Oncology
  • Urology
ID:
104
NQF:
eMeasure ID:
High Priority:
No

2023 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
Specifications
Specialty
  • Urology
ID:
107
NQF:
0104e
eMeasure ID:
CMS161v11
High Priority:
No

2023 MIPS Measure #107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:
110
NQF:
0041
eMeasure ID:
CMS147v12
High Priority:
No

2023 MIPS Measure #110: Preventive Care and Screening: Influenza Immunization (MVP only)

Percentage of patients aged 6 months and older seen for a visit during the measurement period who received an influenza immunization OR who reported previous receipt of an influenza immunization. Please note that this quality measure was removed from Traditional MIPS. This measure will be available for MVP reporting.

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:
111
NQF:
eMeasure ID:
CMS127v10
High Priority:
No

2023 MIPS Measure #111: Pneumococcal Vaccination Status for Older Adults (MVP only)

Percentage of patients 66 years of age and older who have received a pneumococcal vaccine. Please note that this quality measure was removed from Traditional MIPS. This measure will be available for MVP reporting.

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:
112
NQF:
2372
eMeasure ID:
CMS125v11
High Priority:
No

2023 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:
113
NQF:
0034
eMeasure ID:
CMS130v11
High Priority:
No

2023 MIPS Measure #113: Colorectal Cancer Screening

Percentage of patients 45-75 years of age who had appropriate screening for colorectal cancer

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Preventive Medicine
ID:
116
NQF:
0058
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #116: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis

The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Internal Medicine
  • Pediatrics
  • Preventive Medicine
  • Urgent Care
ID:
117
NQF:
0055
eMeasure ID:
CMS131v11
High Priority:
No

2023 MIPS Measure #117: Diabetes: Eye Exam

Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Endocrinology
  • Family Medicine
  • Internal Medicine
  • Ophthalmology
ID:
118
NQF:
0066
eMeasure ID:
High Priority:
No

2023 MIPS 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%)

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB therapy.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Endocrinology
  • Skilled Nursing Facility
ID:
126
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Endocrinology
  • Family Medicine
  • Internal Medicine
  • Physical Therapy/Occupational Therapy
  • Podiatry
  • Preventive Medicine
ID:
127
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.

Measure Type
  • Process
Specifications
Specialty
  • Physical Therapy/Occupational Therapy
  • Podiatry
ID:
128
NQF:
eMeasure ID:
CMS69v11
High Priority:
No

2023 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 the 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:
CMS68v12
High Priority:
Yes

2023 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 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:
134
NQF:
eMeasure ID:
CMS2v12
High Priority:
No

2023 MIPS Measure #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.

Measure Type
  • Process
Specifications
Specialty
  • Audiology
  • Clinical Social Work
  • Emergency Medicine
  • Endocrinology
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Mental/Behavioral Health
  • Neurology
  • Orthopedic Surgery
  • Pediatrics
  • Physical Therapy/Occupational Therapy
  • Preventive Medicine
  • Speech/Language Pathology
  • Urology
ID:
137
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #137: Melanoma: Continuity of Care – Recall System

Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:

  • A target date for the next complete physical skin exam, AND
  • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment
Measure Type
  • Structure
Specifications
Specialty
  • Dermatology
ID:
138
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #138: Melanoma: Coordination of Care

Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
ID:
141
NQF:
0563
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
143
NQF:
0384
eMeasure ID:
CMS157v11
High Priority:
Yes

2023 MIPS Measure #143: Oncology: Medical and Radiation – Pain Intensity Quantified

Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
  • Radiation Oncology
ID:
144
NQF:
0383
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #144: Oncology: Medical and Radiation – Plan of Care for Pain

Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
  • Radiation Oncology
ID:
145
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #145: Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy

Final reports for procedures using fluoroscopy that document radiation exposure indices.

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
  • Interventional Radiology
ID:
147
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #147: Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed.

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:
155
NQF:
0101
eMeasure ID:
High Priority:
Yes

2023 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:
164
NQF:
0129
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:
167
NQF:
0114
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:
168
NQF:
0115
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:
176
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #176: Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy

If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Rheumatology
ID:
177
NQF:
2523
eMeasure ID:
High Priority:
No

2023 MIPS Measure #177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the measurement year.

Measure Type
  • Process
Specifications
Specialty
  • Rheumatology
ID:
178
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
  • Rheumatology
ID:
180
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #180: Rheumatoid Arthritis (RA): Glucocorticoid Management

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
  • Rheumatology
ID:
181
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #181: Elder Maltreatment Screen and Follow-Up Plan

Percentage of patients aged 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.

Measure Type
  • Process
Specifications
Specialty
  • Audiology
  • Clinical Social Work
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Mental/Behavioral Health
  • Neurology
  • Nutrition/Dietician
  • Physical Therapy/Occupational Therapy
  • Skilled Nursing Facility
  • Speech/Language Pathology
ID:
182
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #182: Functional Outcome Assessment

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies within two days of the date of the identified deficiencies.

Measure Type
  • Process
Specifications
Specialty
  • Audiology
  • Chiropractic Medicine
  • Family Medicine
  • Nephrology
  • Orthopedic Surgery
  • Physical Medicine
  • Physical Therapy/Occupational Therapy
  • Preventive Medicine
  • Speech/Language Pathology
ID:
185
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #185: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:
187
NQF:
eMeasure ID:
High Priority:
No

2022 MIPS Measure #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Emergency Medicine
  • Neurosurgery
ID:
191
NQF:
0565
eMeasure ID:
CMS133v11
High Priority:
Yes

2023 MIPS Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
205
NQF:
0409
eMeasure ID:
High Priority:
No

2023 MIPS Measure #205: HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection.

Measure Type
  • Process
Specifications
Specialty
  • Infectious Disease
  • Pediatrics
ID:
217
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #217: Functional Status Change for Patients with Knee Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with knee impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
218
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #218: Functional Status Change for Patients with Hip Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with hip impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
219
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with foot, ankle or lower leg impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
220
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #220: Functional Status Change for Patients with Low Back Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with low back impairments. The change in FS is assessed using the FOTO Low Back FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
221
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #221: Functional Status Change for Patients with Shoulder Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in FS is assessed using the FOTO Shoulder FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
222
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the FOTO Elbow/Wrist/Hand FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
226
NQF:
0028
eMeasure ID:
CMS138v11
High Priority:
No

2023 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 during the measurement period or in the six months prior to the measurement period 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
  • Geriatrics
  • 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
  • Podiatry
  • Preventive Medicine
  • Pulmonology
  • Radiation Oncology
  • Rheumatology
  • Speech/Language Pathology
  • Thoracic Surgery
  • Urgent Care
  • Urology
  • Vascular Surgery
ID:
236
NQF:
eMeasure ID:
CMS165v11
High Priority:
Yes

2023 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:
238
NQF:
0022
eMeasure ID:
CMS156v11
High Priority:
Yes

2023 MIPS Measure #238: Use of High-Risk Medications in Older Adults

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Oncology/Hematology
  • Ophthalmology
  • Otolaryngology
  • Pulmonology
  • Rheumatology
  • Skilled Nursing Facility
  • Urology
ID:
239
NQF:
eMeasure ID:
CMS155v11
High Priority:
No

2023 MIPS Measure #239: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

- Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
- Percentage of patients with counseling for nutrition
- Percentage of patients with counseling for physical activity

Measure Type
  • Process
Specifications
Specialty
  • Nutrition/Dietician
  • Pediatrics
ID:
240
NQF:
eMeasure ID:
CMS117v11
High Priority:
No

2023 MIPS Measure #240: Childhood Immunization Status

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (Hib); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

Measure Type
  • Process
Specifications
Specialty
  • Infectious Disease
  • Pediatrics
ID:
243
NQF:
0643
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting

Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.

Definition:

Referral - A “referral” is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).

NOTE: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months. In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Preventive Medicine
ID:
249
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #249: Barrett’s Esophagus

Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia.

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:
250
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #250: Radical Prostatectomy Pathology Reporting

Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
  • Pathology
ID:
254
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #254: Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
ID:
259
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #259: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)

Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).

Measure Type
  • Outcome
Specifications
Specialty
  • Vascular Surgery
ID:
260
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #260: Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)

Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) who are discharged to home no later than post-operative day #2.

Measure Type
  • Outcome
Specifications
Specialty
  • Neurosurgery
  • Vascular Surgery
ID:
261
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.

Measure Type
  • Process
Specifications
Specialty
  • Audiology
ID:
264
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #264: Sentinel Lymph Node Biopsy for Invasive Breast Cancer

The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.

Measure Type
  • Process
Specifications
Specialty
  • General Surgery
ID:
268
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:
275
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:
277
NQF:
eMeasure ID:
High Priority:
No

2023 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) ,a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea.

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

2023 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:
281
NQF:
2872e
eMeasure ID:
CMS149v11
High Priority:
No

2023 MIPS Measure #281: Dementia: Cognitive Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

Measure Type
  • Process
Specifications
Specialty
  • Clinical Social Work
  • Geriatrics
  • Mental/Behavioral Health
  • Neurology
  • Physical Therapy/Occupational Therapy
ID:
282
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #282: Dementia: Functional Status Assessment

Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Clinical Social Work
  • Geriatrics
  • Mental/Behavioral Health
  • Neurology
ID:
283
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Clinical Social Work
  • Geriatrics
  • Mental/Behavioral Health
  • Neurology
  • Physical Therapy/Occupational Therapy
ID:
286
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.

Measure Type
  • Process
Specifications
Specialty
  • Clinical Social Work
  • Geriatrics
  • Mental/Behavioral Health
  • Neurology
  • Physical Therapy/Occupational Therapy
ID:
288
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #288: Dementia: Education and Support of Caregivers for Patients with Dementia

Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.

Measure Type
  • Process
Specifications
Specialty
  • Clinical Social Work
  • Geriatrics
  • Mental/Behavioral Health
  • Neurology
  • Physical Therapy/Occupational Therapy
ID:
290
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #290: Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease

Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for depression, anxiety, apathy, AND psychosis once during the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:
291
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #291: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease

Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:
293
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #293: Rehabilitative Therapy Referral for Patients with Parkinson’s Disease

Percentage of all patients with a diagnosis of Parkinson’s Disease who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:
303
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
304
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
305
NQF:
eMeasure ID:
CMS137v11
High Priority:
Yes

2023 MIPS Measure #305: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported):

a. Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode.
b. Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
  • Pediatrics
ID:
309
NQF:
eMeasure ID:
CMS124v11
High Priority:
No

2023 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:
CMS153v11
High Priority:
No

2023 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:
CMS22v11
High Priority:
No

2023 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:
318
NQF:
0101
eMeasure ID:
CMS139v11
High Priority:
Yes

2023 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
  • Geriatrics
  • Internal Medicine
  • Nephrology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Therapy/Occupational Therapy
  • Podiatry
ID:
320
NQF:
0658
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

Percentage of patients aged 45 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:
321
NQF:
0005
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #321: CAHPS for MIPS Clinician/Group Survey

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows:                                                   •

  • Getting timely care, appointments, and information (Not endorsed by NQF);
  • How well providers Communicate (Not endorsed by NQF);
  • Patient’s Rating of Provider (NQF endorsed #0005);
  • Access to Specialists (Not endorsed by NQF);
  • Health Promotion & Education (Not endorsed by NQF);
  • Shared Decision Making (Not endorsed by NQF);
  • Health Status/Functional Status (Not endorsed by NQF);
  • Courteous and Helpful Office Staff (NQF endorsed #0005);
  • Care Coordination (Not endorsed by NQF); and
  • Stewardship of Patient Resources (Not endorsed by NQF).
Measure Type
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Oncology/Hematology
  • Urology
ID:
322
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #322: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients

Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period.

Measure Type
  • Efficiency
Specifications
Specialty
  • Cardiology
ID:
324
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #324: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.

Measure Type
  • Efficiency
Specifications
Specialty
  • Cardiology
ID:
326
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Skilled Nursing Facility
ID:
331
NQF:
eMeasure ID:
High Priority:
Yes

2023 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

2023 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:
335
NQF:
eMeasure ID:
High Priority:
Yes

2023 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

2023 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:
338
NQF:
2082
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #338: HIV Viral Load Suppression

The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.

Measure Type
  • Outcome
Specifications
Specialty
  • Allergy/Immunology
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
ID:
340
NQF:
2079
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #340: HIV Medical Visit Frequency

Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Infectious Disease
ID:
344
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.

Measure Type
  • Outcome
Specifications
Specialty
  • Cardiology
  • Neurosurgery
  • Vascular Surgery
ID:
350
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #350: Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

Percentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:
351
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

Percentage of patients regardless of age undergoing a total knee or total hip replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:
354
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #354:Anastomotic Leak Intervention

Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.

Measure Type
  • Outcome
Specifications
Specialty
  • General Surgery
ID:
355
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #355: Unplanned Reoperation within the 30 Day Postoperative Period

Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.

Measure Type
  • Outcome
Specifications
Specialty
  • General Surgery
  • Otolaryngology
  • Plastic Surgery
ID:
356
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #356: Unplanned Hospital Readmission within 30 Days of Principal Procedure

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.

Measure Type
  • Outcome
Specifications
Specialty
  • General Surgery
  • Plastic Surgery
  • Thoracic Surgery
ID:
357
NQF:
eMeasure ID:
High Priority:
Yes

2023 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

2023 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:
360
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:
364
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:
366
NQF:
eMeasure ID:
CMS136v12
High Priority:
No

2023 MIPS Measure #366: Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.

a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Pediatrics
ID:
370
NQF:
0710
eMeasure ID:
CMS159v11
High Priority:
Yes

2023 MIPS Measure #370: Depression Remission at Twelve Months

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.

Measure Type
  • Outcome
Specifications
Specialty
  • Clinical Social Work
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Mental/Behavioral Health
  • Pediatrics
ID:
374
NQF:
eMeasure ID:
CMS50v11
High Priority:
Yes

2023 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician 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:
376
NQF:
eMeasure ID:
CMS56v11
High Priority:
Yes

2023 MIPS Measure #376: Functional Status Assessment for Total Hip Replacement

Percentage of patients 19 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270 - 365 days after the surgery

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:
377
NQF:
eMeasure ID:
CMS90v12
High Priority:
Yes

2023 MIPS Measure #377: Functional Status Assessments for Heart Failure

Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
ID:
378
NQF:
eMeasure ID:
CMS75v11
High Priority:
Yes

2023 MIPS Measure #378: Children Who Have Dental Decay or Cavities

Percentage of children, 6 months - 20 years of age at the start of the measurement period, who have had tooth decay or cavities during the measurement period as determined by a dentist

Measure Type
  • Outcome
Specifications
Specialty
  • Dentistry
ID:
379
NQF:
eMeasure ID:
CMS74v12
High Priority:
No

2023 MIPS Measure #379: Primary Caries Prevention Intervention as Offered by Dentists

Percentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement period as determined by a dentist

Measure Type
  • Process
Specifications
Specialty
  • Dentistry
ID:
382
NQF:
1365e
eMeasure ID:
CMS177v11
High Priority:
Yes

2023 MIPS Measure #382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

Measure Type
  • Process
Specifications
Specialty
  • Clinical Social Work
  • Mental/Behavioral Health
  • Pediatrics
ID:
383
NQF:
1879
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Clinical Social Work
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:
384
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
385
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
386
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually.

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:
387
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #387: Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
ID:
389
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #389: Cataract Surgery: Difference Between Planned and Final Refraction

Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:
391
NQF:
0576
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #391:Follow-Up After Hospitalization for Mental Illness (FUH)

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are submitted:

  • The percentage of discharges for which the patient received follow-up within 30 days after discharge
  • The percentage of discharges for which the patient received follow-up within 7 days after discharge
Measure Type
  • Process
Specifications
Specialty
  • Internal Medicine
  • Mental/Behavioral Health
  • Pediatrics
ID:
392
NQF:
2474
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #392: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:

  • Submission Age Criteria 1: Females 18-64 years of age
  • Submission Age Criteria 2: Males 18-64 years of age
  • Submission Age Criteria 3: Females 65 years of age and older
  • Submission Age Criteria 4: Males 65 years of age and older
Measure Type
  • Outcome
Specifications
Specialty
  • Electrophysiology Cardiac Specialist
ID:
393
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

Infection rate following CIED device implantation, replacement, or revision.

Measure Type
  • Outcome
Specifications
Specialty
  • Electrophysiology Cardiac Specialist
ID:
394
NQF:
1407
eMeasure ID:
High Priority:
No

2023 MIPS Measure #394: Immunizations for Adolescents

The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Pediatrics
ID:
395
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #395:Lung Cancer Reporting (Biopsy/Cytology Specimens)

Pathology reports based on lung biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type following the International Association for the Study of Lung Cancer (IASLC) guidance or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:
396
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #396: Lung Cancer Reporting (Resection Specimens)

Pathology reports based on lung resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:
397
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #397: Melanoma Reporting

Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:
398
NQF:
eMeasure ID:
High Priority:
Yes

2023 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:
400
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #400: One-Time Screening for Hepatitis C Virus (HCV) for all Patients

Percentage of patients age >= 18 years who received one-time screening for hepatitis C virus (HCV) infection.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Nephrology
ID:
401
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #401: Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Gastroenterology
  • Internal Medicine
ID:
402
NQF:
eMeasure ID:
High Priority:
No

2023 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
  • Pulmonology
  • Rheumatology
  • Thoracic Surgery
  • Urgent Care
  • Vascular Surgery
ID:
404
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #404: Anesthesiology Smoking Abstinence

The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Anesthesiology
ID:
405
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions

Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow‐up imaging recommended based on radiological findings:

  • Cystic renal lesion that is simple appearing* (Bosniak I or II)
  • Adrenal lesion less than or equal to 1.0 cm
  • Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols
Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:
406
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:
409
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #409: Clinical Outcome Post Endovascular Stroke Treatment

Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.

Measure Type
  • Outcome
Specifications
Specialty
  • Interventional Radiology
  • Neurosurgery
ID:
410
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #410: Psoriasis: Clinical Response to Systemic Medications

Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.

Measure Type
  • Outcome
Specifications
Specialty
  • Dermatology
ID:
413
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #413: Door to Puncture Time for Endovascular Stroke Treatment

Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Interventional Radiology
  • Neurosurgery
ID:
415
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.

Measure Type
  • Efficiency
Specifications
Specialty
  • Emergency Medicine
ID:
416
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years

Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.

Measure Type
  • Efficiency
Specifications
Specialty
  • Emergency Medicine
ID:
418
NQF:
0053
eMeasure ID:
High Priority:
No

2023 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:
419
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #419: Overuse of Imaging for the Evaluation of Primary Headache

Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present.

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:
420
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #420: Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.

Measure Type
  • Outcome
Specifications
Specialty
  • Interventional Radiology
  • Vascular Surgery
ID:
421
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #421: Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal

Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal, or the inability to contact the patient with at least two attempts.

Measure Type
  • Process
Specifications
Specialty
  • Interventional Radiology
ID:
422
NQF:
2063
eMeasure ID:
High Priority:
Yes

2023 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:
424
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #424: Perioperative Temperature Management

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

Measure Type
  • Outcome
Specifications
Specialty
  • Anesthesiology
ID:
430
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:
431
NQF:
2152
eMeasure ID:
High Priority:
No

2023 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
  • Audiology
  • 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

2023 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

2023 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:
436
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

Percentage of final reports for patients aged 18 years and older undergoing computed tomography (CT) with documentation that one or more of the following dose reduction techniques were used.

  • Automated exposure control
  • Adjustment of the mA and/or kV according to patient size
  • Use of iterative reconstruction technique
Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:
438
NQF:
eMeasure ID:
CMS347v6
High Priority:
No

2023 MIPS Measure #438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:

  • All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
  • Patients aged ≥ 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
  • Patients aged 40-75 years with a diagnosis of diabetes.
Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Endocrinology
  • Family Medicine
  • Internal Medicine
  • Preventive Medicine
ID:
439
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #439: Age Appropriate Screening Colonoscopy

The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.

Measure Type
  • Efficiency
Specifications
Specialty
  • Gastroenterology
ID:
440
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #440: Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician

Percentage of biopsies with a diagnosis of cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
  • Pathology
ID:
441
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:

  • Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND
  • Most recent tobacco status is Tobacco Free -- AND
  • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND
  • Statin Use Unless Contraindicated
Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Vascular Surgery
ID:
443
NQF:
eMeasure ID:
High Priority:
Yes

2023 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:
445
NQF:
0119
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:
448
NQF:
eMeasure ID:
High Priority:
Yes

2023 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:
450
NQF:
1858
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #450: Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer

Percentage of female patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
ID:
451
NQF:
1859
eMeasure ID:
High Priority:
No

2023 MIPS Measure #451: RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer Who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy

Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
ID:
452
NQF:
1860
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #452: Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies

Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
ID:
453
NQF:
0210
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #453: Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)

Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
  • Urology
ID:
457
NQF:
0216
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #457: Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)

Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.

Measure Type
  • Outcome
Specifications
Specialty
  • Oncology/Hematology
  • Urology
ID:
459
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #459: Back Pain After Lumbar Surgery

For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.

Measure Type
  • Outcome
Specifications
Specialty
  • Neurosurgery
  • Orthopedic Surgery
ID:
461
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #461: Leg Pain After Lumbar Surgery

For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.

Measure Type
  • Outcome
Specifications
Specialty
  • Neurosurgery
  • Orthopedic Surgery
ID:
462
NQF:
eMeasure ID:
CMS645v6
High Priority:
No

2023 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
Specifications
Specialty
  • Endocrinology
  • Oncology/Hematology
  • Urology
ID:
463
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)

Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:
464
NQF:
0657
eMeasure ID:
High Priority:
Yes

2023 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
ID:
465
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #465: Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.

Measure Type
  • Process
Specifications
Specialty
  • Interventional Radiology
ID:
468
NQF:
3175
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #468: Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
  • Physical Medicine
ID:
470
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #470: Functional Status After Primary Total Knee Replacement

For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR. tool at one year (9 to 15 months) postoperatively.

Measure Type
  • Outcome
Specifications
Specialty
  • Orthopedic Surgery
ID:
471
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #471: Functional Status After Lumbar Surgery

For patients age 18 and older who had lumbar discectomy/laminectomy or fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.
* hereafter referred to as ODI

Measure Type
  • Outcome
Specifications
Specialty
  • Neurosurgery
  • Orthopedic Surgery
ID:
472
NQF:
3475e
eMeasure ID:
CMS249v5
High Priority:
Yes

2023 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:
CMS349v5
High Priority:
No

2023 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 Human immunodeficiency virus (HIV)

Measure Type
  • Process
Specifications
Specialty
  • Certified Nurse Midwife
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Obstetrics/Gynecology
  • Preventive Medicine
ID:
476
NQF:
eMeasure ID:
CMS771v4
High Priority:
Yes

2023 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
Specifications
Specialty
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Urology
ID:
477
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #477: Multimodal Pain Management

Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:
478
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #478: Functional Status Change for Patients with Neck Impairments

A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Measure Type
  • Outcome
Specifications
Specialty
  • Chiropractic Medicine
  • Orthopedic Surgery
  • Physical Therapy/Occupational Therapy
ID:
479
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups

This measure is a re-specified version of the measure, “Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition” (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group’s readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:
480
NQF:
3493
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #480: Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)

This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.

Measure Type
  • Outcome
Specifications
Specialty
  • Orthopedic Surgery
ID:
481
NQF:
eMeasure ID:
CMS646v3
High Priority:
Yes

2023 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
Specifications
Specialty
  • Urology
ID:
482
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #482: Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate

Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Nephrology
ID:
483
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #483: Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)

The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.

Measure Type
  • Outcome
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
ID:
484
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:
485
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #485: Psoriasis – Improvement in Patient-Reported Itch Severity

The percentage of patients, aged 18 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.

Measure Type
  • Outcome
Specifications
Specialty
  • Dermatology
ID:
486
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #486: Dermatitis – Improvement in Patient-Reported Itch Severity

The percentage of patients, aged 18 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.

Measure Type
  • Outcome
Specifications
Specialty
  • Dermatology
ID:
487
NQF:
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #487: Screening for Social Drivers of Health

Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Audiology
  • Cardiology
  • Certified Nurse Midwife
  • Chiropractic Medicine
  • Clinical Social Work
  • Dermatology
  • Emergency Medicine
  • Endocrinology
  • Family Medicine
  • Gastroenterology
  • General Surgery
  • Geriatrics
  • Infectious Disease
  • Internal Medicine
  • Interventional Radiology
  • Mental/Behavioral Health
  • Nephrology
  • Neurology
  • Neurosurgery
  • Nutrition/Dietician
  • Obstetrics/Gynecology
  • Oncology/Hematology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Pediatrics
  • Physical Medicine
  • Physical Therapy/Occupational Therapy
  • Plastic Surgery
  • Podiatry
  • Preventive Medicine
  • Pulmonology
  • Rheumatology
  • Skilled Nursing Facility
  • Thoracic Surgery
  • Urgent Care
  • Urology
  • Vascular Surgery
ID:
488
NQF:
eMeasure ID:
CMS951v1
High Priority:
No

2023 MIPS Measure #488: Kidney Health Evaluation

Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Endocrinology
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Nephrology
  • Preventive Medicine
  • Urology
ID:
489
NQF:
1662
eMeasure ID:
High Priority:
No

2023 MIPS Measure #489: Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy

Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.

Measure Type
  • Process
Specifications
Specialty
  • Geriatrics
  • Nephrology
ID:
490
NQF:
eMeasure ID:
High Priority:
No

2023 MIPS Measure #490: Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors

Percentage of patients, aged 18 years and older, with a diagnosis of cancer, on immune checkpoint inhibitor therapy, and grade 2 or above diarrhea and/or grade 2 or above colitis, who have immune checkpoint inhibitor therapy held and corticosteroids or immunosuppressants prescribed or administered.

Measure Type
  • Process
Specifications
Specialty
  • Oncology/Hematology
ID:
491
NQF:
3661
eMeasure ID:
High Priority:
Yes

2023 MIPS Measure #491: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma

Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:
493
NQF:
3620
eMeasure ID:
High Priority:
No

2023 MIPS Measure #493: Adult Immunization Status

Percentage of patients 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; and pneumococcal.

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

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