- 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:112NQF:2372eMeasure ID:CMS125v11High Priority:No2023 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
Specialty- Family Medicine
- Obstetrics/Gynecology
- Preventive Medicine
ID:128NQF:eMeasure ID:CMS69v11High Priority:No2023 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
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nutrition/Dietician
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
- Vascular Surgery
ID:130NQF:eMeasure ID: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:236NQF:eMeasure ID:CMS165v11High Priority:Yes2023 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
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
- Pulmonology
- Rheumatology
- Vascular Surgery
ID:309NQF:eMeasure ID:CMS124v11High Priority:No2023 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 yearsMeasure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
ID:310NQF:eMeasure ID:CMS153v11High Priority:No2023 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
SpecificationsSpecialty- Obstetrics/Gynecology
- Pediatrics
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:335NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Certified Nurse Midwife
- Obstetrics/Gynecology
ID:336NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Certified Nurse Midwife
- Obstetrics/Gynecology
ID:374NQF:eMeasure ID:CMS50v11High Priority:Yes2023 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
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: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:418NQF:0053eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Endocrinology
- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
- Orthopedic Surgery
ID:422NQF:2063eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Obstetrics/Gynecology
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:432NQF:eMeasure ID:High Priority:Yes2023 MIPS Measure #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:433NQF:eMeasure ID:High Priority:Yes2023 MIPS Measure #433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:443NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
ID:448NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Obstetrics/Gynecology
ID:472NQF:3475eeMeasure ID:CMS249v5High Priority:Yes2023 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
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
ID:475NQF:eMeasure ID:CMS349v5High Priority:No2023 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
SpecificationsSpecialty- Certified Nurse Midwife
- Family Medicine
- Infectious Disease
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
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: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_AHE_6 - Provide Education Opportunities for New Clinicians (high weighted).
- IA_BE_6 - Regularly Assess Patient Experience of Care and Follow Up on Findings (high weighted).
- IA_BE_15 - Engagement of Patients, Family, and Caregivers in Developing a Plan of Care (medium weighted).
- IA_PM_5-Engagement of community for health status improvement (medium weighted).
- IA_PM_6-Use of toolsets or other resources to close healthcare disparities across communities (medium weighted).
- IA_PM_11-Regular Review Practices in Place on Targeted Patient Population Needs (medium weighted).
- IA_PM_15-Implementation of episodic care management practice improvements (medium weighted).
- IA_PM_21-Advance Care Planning (medium weighted).
- IA_PSPA_1-Participation in an AHRQ-listed patient safety organization. (medium weighted).
- IA_PSPA_17- Implementation of analytic capabilities to manage total cost of care for practice population (medium weighted).
- IA_PSPA_19-Implementation of formal quality improvement methods, practice changes or other practice improvement processes (medium weighted).
- IA_PSPA_22-CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain (high weighted).
- IA_PSPA_31- Patient Medication Risk Education (medium weighted).
- IA_PSPA_32- Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support (high weighted).
- Full list of Improvement Activities