- Quality - 30% of total score: Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to receive a score against 2023 National Benchmarks. Suggestions for your specialty include, but are not limited to, the following: ID:065NQF:0069eMeasure ID:CMS154v11High 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
Specialty- Emergency Medicine
- Family Medicine
- Infectious Disease
- Pediatrics
- Urgent Care
ID:066NQF:eMeasure ID:CMS146v11High Priority:Yes2023 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
Specialty- Emergency Medicine
- Family Medicine
- Otolaryngology
- Pediatrics
- Urgent Care
ID:093NQF:0654eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Emergency Medicine
- Family Medicine
- Internal Medicine
- Otolaryngology
- Pediatrics
- Urgent Care
ID:116NQF:0058eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Emergency Medicine
- Family Medicine
- Internal Medicine
- Pediatrics
- Preventive Medicine
- Urgent Care
ID:130NQF:eMeasure ID:CMS68v12High Priority:Yes2023 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
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- Certified Nurse Midwife
- Clinical Social Work
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Geriatrics
- Hospitalists
- Infectious Disease
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Neurosurgery
- Nutrition/Dietician
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Preventive Medicine
- Pulmonology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:226NQF:0028eMeasure ID:CMS138v11High Priority:No2023 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
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:317NQF:eMeasure ID:CMS22v11High Priority:No2023 MIPS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Emergency Medicine
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Plastic Surgery
- Preventive Medicine
- Rheumatology
- Skilled Nursing Facility
- Urgent Care
- Urology
- Vascular Surgery
ID:331NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Allergy/Immunology
- Emergency Medicine
- Family Medicine
- Internal Medicine
- Otolaryngology
- Urgent Care
ID:332NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Allergy/Immunology
- Emergency Medicine
- Family Medicine
- Internal Medicine
- Otolaryngology
- Urgent Care
ID:402NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- 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:431NQF:2152eMeasure ID:High Priority:No2023 MIPS Measure #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user.
Measure Type- Process
SpecificationsSpecialty- 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:464NQF:0657eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Family Medicine
- Otolaryngology
- Pediatrics
- Urgent Care
ID:487NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Allergy/Immunology
- Audiology
- Cardiology
- Certified Nurse Midwife
- Chiropractic Medicine
- Clinical Social Work
- Dermatology
- Diagnostic Radiology
- 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
- PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Cures Update must be in place by October 3, 2023. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 55% of your score.
- e-Prescribing
- Query of Prescription Drug Monitoring Program (PDMP) (optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops by Sending Health Information (option 1)
- Support Electronic Referral Loops by Receiving and Reconciling Health Information (option 1)
- Health Information Exchange (HIE) Bi-Directional Exchange (option 2)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- IA: Improvement Activities - 15% of total score: Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year. There are over 100 possible activities to choose from. The following are suggestions for your specialty:
- IA_EPA_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_AHE_1 - Enhance Engagement of Medicaid and Other Underserved Populations (high weighted).
- IA_BE_14 - Engage patients and families to guide improvement in the system of care (high weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- Full list of Improvement Activities