MVP ID: G0058
Most applicable medical specialty(s):
Orthopedic Surgery
The Improving Care for Lower Extremity Joint Repair MVP focuses on the clinical theme of providing fundamental treatment and management of patients with osteoarthritis and lower extremity surgical repair, such as fracture and total joint replacement, to ensure appropriate care and reduce costs.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 024: Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older - Process, High Priority, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan - Process, High Priority: No, eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 350: Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy - Process, High Priority, MIPS CQMs
- Quality ID: 351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation - Process, High Priority, MIPS CQMs
- Quality ID: 376: Functional Status Assessment for Total Hip Replacement - Process, High Priority, eCQMs
- Quality ID: 470: Functional Status After Primary Total Knee Replacement - Patient Reported Outcome, High Priority, MIPS CQMs
- Quality ID: 487: Screening for Social Drivers of Health - Process, High Priority, MIPS CQMs
- Quality ID: 480: Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for MIPS - Outcome, High Priority
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_AHE_3: Promote Use of Patient-Reported Outcome Tools - High
- IA_BE_12: Use evidence-based decision aids to support shared decision-making - Medium
- IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings - High
- IA_CC_13: Practice Improvements to Align with OpenNotes Principles - Medium
- IA_CC_15: PSH Care Coordination - High
- IA_CC_7: Regular training in care coordination - Medium
- IA_CC_9: Implementation of practices/processes for developing regular individual care plans - Medium
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways - High
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PSPA_18: Measurement and improvement at the practice and panel level - Medium
- IA_PSPA_27: Invasive Procedure or Surgery Anticoagulation Medication Management - Medium
- IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements - Medium
Cost
Calculated by CMS using administrative claims data:
Population Health Measures
Select one population health measure to be scored by CMS using administrative claims data:
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Prevention of Information Blocking
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP) (Optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review
MVP Registration
- MVP Participants must register between April 1 – December 2, 2024 to report an MVP in 2024.
- To register, MVP Participants must select:
- The MVP they intend to report.
- 1 population health measure included in the MVP.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 2, 2024).
- Report on an MVP they didn’t register for during the 2024 performance year.
- Report on more than one MVP.