MVP ID: M1367
Most applicable medical specialty(s):
Otolaryngology
The Quality Care for the Treatment of Ear, Nose, and Throat Disorders MVP focuses on the clinical theme of providing care for patients experiencing some of the most common otolaryngology conditions such as, but not limited to: otologic conditions, chronic rhinosinusitis (CRS), age-related hearing loss (ARHL) and otitis media.
Quality
- Quality ID: 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan - Process, eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - Process, eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 277: Sleep Apnea: Severity Assessment at Initial Diagnosis - Process, MIPS CQMs
- Quality ID: 331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) - Process, High Priority, MIPS CQMs
- Quality ID: 332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) - Process, High Priority, MIPS CQMs
- Quality ID: 355: Unplanned Reoperation within the 30 Day Postoperative Period - Outcome, High Priority, MIPS CQMs
- Quality ID: 357: Surgical Site Infection (SSI) - Outcome, High Priority, MIPS CQMs
- Quality ID: 487: Screening for Social Drivers of Health - Process, High Priority, MIPS CQMs
- Quality ID: AAO16: Age-Related Hearing Loss: Comprehensive Audiometric Evaluation - Process, High Priority, QCDR
- Quality ID: AAO20: Tympanostomy Tubes: Comprehensive Audiometric Evaluation - Process, QCDR
- Quality ID: AAO21: Otitis Media with Effusion (OME): Comprehensive Audiometric Evaluation for Chronic OME > or = 3 months - Process, QCDR
- Quality ID: AAO23: Allergic Rhinitis: Intranasal Corticosteroids or Oral Antihistamines - Process, QCDR
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_AHE_5: MIPS Eligible Clinician Leadership in Clinical Trials or CBPR - Medium
- IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care - Medium
- IA_BE_4: Engagement of patients through implementation of improvements in patient portal - Medium
- IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop - Medium
- IA_CC_13: Practice Improvements to Align with OpenNotes Principles - Medium
- IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record - High
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways - High
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_16: Implementation of medication management practice improvements - 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.