2024 MIPS Measures Relevant to Gastroenterology

  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 against 2023 National Benchmarks. Suggestions for your specialty include, but are not limited to, the following: 

     

    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:
    185
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #185: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

    Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.

    Measure Type
    • Process
    Specifications
    Specialty
    • Gastroenterology
    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:
    275
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

    Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.

    Measure Type
    • Process
    Specifications
    Specialty
    • Gastroenterology
    ID:
    317
    NQF:
    eMeasure ID:
    CMS22v12
    High Priority:
    No

    2024 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
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Oncology/Hematology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Plastic Surgery
    • Podiatry
    • Rheumatology
    • Skilled Nursing Facility
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    320
    NQF:
    0658
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

    Percentage of patients aged 45 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.

    Measure Type
    • Process
    Specifications
    Specialty
    • Gastroenterology
    ID:
    374
    NQF:
    eMeasure ID:
    CMS50v12
    High Priority:
    Yes

    2024 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
    Specifications
    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:
    401
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #401: Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

    Percentage of patients aged 18 years and older with a diagnosis of chronic Hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Gastroenterology
    • Internal Medicine
    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:
    439
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #439: Age Appropriate Screening Colonoscopy

    The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Gastroenterology
    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:
    503
    NQF:
    2483
    eMeasure ID:
    High Priority:
    Yes

    2024 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
    Specifications
    Specialty
    • 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
    • *These registry measures make-up the Gastroenterology Specialty Measures Set.
  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 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 are suggestions for your specialty:

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