2023 MIPS Measures Relevant to Endocrinology

  1. Quality - 30% of total score:  Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to receive a score against 2022 National Benchmarks. Suggestions for your specialty include, but are not limited to, the following:   
    ID:
    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:
    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:
    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:
    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:
    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:
    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:
    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:
    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:
    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:
    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:
    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
     
  2. PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 2022. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 55% of your score.
  3. IA: Improvement Activities - 15% of total score:  Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area,  attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year.  The following are suggestions for your specialty:

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