- Quality - 30% of total score: Choose 6 measures, including one Outcome or other High Priority measure, and include 100% of denominator eligible encounters (entire year, all insurances). Report (provide answers for) at least 75% to receive a score based on 2024 National Benchmarks.
ID:047NQF:0326eMeasure ID:High Priority:Yes2024 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:CMS68v13High Priority:Yes2024 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:CMS138v12High Priority:No2024 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 12 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
- Gastroenterology
- General Surgery
- Infectious Disease
- Mental/Behavioral Health
- Nephrology
- Neurology
- Neurosurgery
- Nutrition/Dietician
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Pediatrics
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Podiatry
- Pulmonology
- Radiation Oncology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:335NQF:eMeasure ID:High Priority:Yes2024 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:Yes2024 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: breastfeeding 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:431NQF:2152eMeasure ID:High Priority:No2024 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:475NQF:eMeasure ID:CMS349v6High Priority:No2024 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:Yes2024 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
- 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
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:496NQF:eMeasure ID:High Priority:No2024 MIPS Measure #496: Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument
Percentage of pregnant or postpartum patients who received a cardiovascular disease (CVD) risk assessment with a standardized instrument.
Measure Type- Process
SpecificationsSpecialty- Certified Nurse Midwife
- Obstetrics/Gynecology
ID:498NQF:eMeasure ID:High Priority:Yes2024 MIPS Measure #498: Connection to Community Service Provider
Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least one of their HRSNs within 60 days after screening.
Measure Type- Process
SpecificationsSpecialty- Allergy/Immunology
- Audiology
- Cardiology
- Certified Nurse Midwife
- Chiropractic Medicine
- Clinical Social Work
- Dermatology
- 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
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:503NQF:2483eMeasure ID:High Priority:Yes2024 MIPS Measure #503: Gains in Patient Activation Measure (PAM) Scores at 12 Months
The Patient Activation Measure® (PAM®) is a 10- or 13-item questionnaire that assesses an individual´s knowledge, skills, and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM® performance measure (PAM®- PM) is the change in score on the PAM® from baseline to follow-up measurement.
Measure Type- Outcome
SpecificationsSpecialty- Allergy/Immunology
- Cardiology
- Certified Nurse Midwife
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- Internal Medicine
- Nephrology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
ID:504NQF:eMeasure ID:High Priority:Yes2024 MIPS Measure #504: Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk
Percentage of adult aged 18 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.
Measure Type- Process
SpecificationsSpecialty- Certified Nurse Midwife
- Clinical Social Work
- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
- Obstetrics/Gynecology
ID:505NQF:eMeasure ID:High Priority:Yes2024 MIPS Measure #505: Reduction in Suicidal Ideation or Behavior Symptoms
The percentage of patients aged 18 years and older with a mental and/or substance use disorder AND suicidal thoughts, behaviors or risk symptoms who demonstrated a reduction in suicidal ideation and/or behavior symptoms based on results from the Columbia-Suicide Severity Rating Scale 'Screen Version' or 'Since Last Visit' (C-SSRS), within 120 days after an index assessment.
Measure Type- Outcome
SpecificationsSpecialty- Certified Nurse Midwife
- Clinical Social Work
- Family Medicine
- Mental/Behavioral Health
- Obstetrics/Gynecology
- PI: Promoting Interoperability - 25% of total score: For a minimum of 180 days, report all required measures. ONC Certified Health IT must be in place by July 4, 2024. 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)
- Enabling Exchange under TEFCA (Option 3)
- 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. Suggestions that might be applicable to your specialty include:
- 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_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_18 -Relationship-centered communication (medium weighted).
- IA_PM_5 -Engagement of community for health status improvement (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).
- Full list of Improvement Activities