- 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:047NQF:0326eMeasure 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
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: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:268NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Neurology
ID:277NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Internal Medicine
- Neurology
- Otolaryngology
- Pulmonology
ID:279NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Internal Medicine
- Neurology
- Otolaryngology
- Pulmonology
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:290NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Neurology
ID:291NQF:eMeasure ID:High Priority:No2023 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
SpecificationsSpecialty- Neurology
ID:293NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Neurology
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: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:386NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Neurology
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:419NQF:eMeasure ID:High Priority:Yes2023 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
SpecificationsSpecialty- Neurology
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: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 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