2024 MIPS Measures Relevant to Clinical Social Work

  1. 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 based on 2023 National Benchmarks.
     
    ID:
    047
    NQF:
    0326
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • 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:
    130
    NQF:
    eMeasure ID:
    CMS68v13
    High Priority:
    Yes

    2024 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
    Specifications
    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:
    134
    NQF:
    eMeasure ID:
    CMS2v13
    High Priority:
    No

    2024 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
    Specifications
    Specialty
    • Audiology
    • Clinical Social Work
    • Emergency Medicine
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Nutrition/Dietician
    • Oncology/Hematology
    • Orthopedic Surgery
    • Pediatrics
    • Physical Therapy/Occupational Therapy
    • Preventive Medicine
    • Speech/Language Pathology
    • Urology
    ID:
    181
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • 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:
    226
    NQF:
    0028
    eMeasure ID:
    CMS138v12
    High Priority:
    No

    2024 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
    Specifications
    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
    • Obstetrics/Gynecology
    • 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:
    281
    NQF:
    2872e
    eMeasure ID:
    CMS149v12
    High Priority:
    No

    2024 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    282
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:
    286
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    288
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    305
    NQF:
    eMeasure ID:
    CMS137v12
    High Priority:
    Yes

    2024 MIPS Measure #305: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

    Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported):

    a. Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode. 
    b. Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.

    Measure Type
    • Process
    Specifications
    Specialty
    • Clinical Social Work
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Pediatrics
    ID:
    370
    NQF:
    0710
    eMeasure ID:
    CMS159v12
    High Priority:
    Yes

    2024 MIPS Measure #370: Depression Remission at Twelve Months

    The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Clinical Social Work
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Pediatrics
    ID:
    382
    NQF:
    1365e
    eMeasure ID:
    CMS177v12
    High Priority:
    Yes

    2024 MIPS Measure #382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

    Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

    Measure Type
    • Process
    Specifications
    Specialty
    • Clinical Social Work
    • Mental/Behavioral Health
    • Pediatrics
    ID:
    383
    NQF:
    1879
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia

    Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Clinical Social Work
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    ID:
    431
    NQF:
    2152
    eMeasure ID:
    High Priority:
    No

    2024 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
    Specifications
    Specialty
    • 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:
    487
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • 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:
    498
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • 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:
    502
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #502: Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder

    The percentage of patients aged 18 and older with a mental and/or substance use disorder who demonstrated improvement or maintenance of functioning based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) or Sheehan Disability Scale (SDS) 30 to 180 days after an index assessment.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Clinical Social Work
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Physical Therapy/Occupational Therapy
    ID:
    504
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • Certified Nurse Midwife
    • Clinical Social Work
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Obstetrics/Gynecology
    ID:
    505
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • Certified Nurse Midwife
    • Clinical Social Work
    • Family Medicine
    • Mental/Behavioral Health
    • Obstetrics/Gynecology
  2. 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.
  3. 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 is a sampling of some of the published IA's that might be applicable to your specialty:

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