- 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:039NQF:0046eMeasure 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
SpecificationsSpecialty- Endocrinology
- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- Rheumatology
ID:047NQF:0326eMeasure ID:High Priority:Yes2023 MIPS Measure #047: Advance Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Certified Nurse Midwife
- Clinical Social Work
- Family Medicine
- Gastroenterology
- General Surgery
- Geriatrics
- Hospitalists
- Internal Medicine
- Nephrology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:048NQF:eMeasure ID:High Priority:No2023 MIPS Measure #048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Physical Therapy/Occupational Therapy
- Preventive Medicine
- Urology
ID:050NQF:eMeasure ID:High Priority:Yes2023 MIPS Measure #050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Physical Therapy/Occupational Therapy
- Urology
ID: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:134NQF:eMeasure ID:CMS2v12High Priority:No2023 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
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:155NQF:0101eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Audiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Neurology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Skilled Nursing Facility
ID:181NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- 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: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:238NQF:0022eMeasure ID:CMS156v11High Priority:Yes2023 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
Specialty- Allergy/Immunology
- Cardiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Oncology/Hematology
- Ophthalmology
- Otolaryngology
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
- Urology
ID:281NQF:2872eeMeasure ID:CMS149v11High Priority:No2023 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
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:282NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
ID:283NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:286NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:288NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:318NQF:0101eMeasure ID:CMS139v11High Priority:Yes2023 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
SpecificationsSpecialty- Audiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Nephrology
- Orthopedic Surgery
- Otolaryngology
- Physical Therapy/Occupational Therapy
- Podiatry
ID:370NQF:0710eMeasure ID:CMS159v11High Priority:Yes2023 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
Specialty- Clinical Social Work
- Family Medicine
- Geriatrics
- Internal Medicine
- Mental/Behavioral Health
- Pediatrics
ID:476NQF:eMeasure ID:CMS771v4High Priority:Yes2023 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points
Measure Type- Outcome
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Urology
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
ID:488NQF:eMeasure ID:CMS951v1High Priority:No2023 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
Specialty- Endocrinology
- Family Medicine
- Geriatrics
- Internal Medicine
- Nephrology
- Preventive Medicine
- Urology
ID:489NQF:1662eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Geriatrics
- Nephrology
ID:493NQF:3620eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Allergy/Immunology
- Cardiology
- Endocrinology
- Family Medicine
- Geriatrics
- Infectious Disease
- Internal Medicine
- Nephrology
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
- 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. 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