2024 MIPS Measures Relevant to Internal Medicine

  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:
    001
    NQF:
    0059
    eMeasure ID:
    CMS122v12
    High Priority:
    Yes

    2024 MIPS Measure #001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

    Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Nutrition/Dietician
    • Preventive Medicine
    ID:
    005
    NQF:
    0081
    eMeasure ID:
    CMS135v12
    High Priority:
    No

    2024 MIPS Measure #005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

    Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Hospitalists
    • Internal Medicine
    ID:
    006
    NQF:
    0067
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #006: Coronary Artery Disease (CAD): Antiplatelet Therapy

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Skilled Nursing Facility
    ID:
    007
    NQF:
    0070
    eMeasure ID:
    CMS145v12
    High Priority:
    No

    2024 MIPS Measure #007: Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker therapy.

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Skilled Nursing Facility
    ID:
    008
    NQF:
    0083
    eMeasure ID:
    CMS144v12
    High Priority:
    No

    2024 MIPS Measure #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

    Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Hospitalists
    • Internal Medicine
    • Skilled Nursing Facility
    ID:
    009
    NQF:
    eMeasure ID:
    CMS128v12
    High Priority:
    No

    2024 MIPS Measure #009: Anti-Depressant Medication Management

    Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported.

    a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).

    b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    ID:
    024
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #024: Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

    Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Orthopedic Surgery
    • Preventive Medicine
    • Rheumatology
    ID:
    039
    NQF:
    0046
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #039: Screening for Osteoporosis for Women Aged 65-85 Years of Age

    Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • Rheumatology
    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:
    048
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

    Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Physical Therapy/Occupational Therapy
    • Preventive Medicine
    • Urology
    ID:
    050
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

    Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Physical Therapy/Occupational Therapy
    • Urology
    ID:
    107
    NQF:
    0104e
    eMeasure ID:
    CMS161v12
    High Priority:
    No

    2024 MIPS Measure #107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

    Percentage of all patient visits for those patients that are 17 years of age or older at the start of the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    ID:
    116
    NQF:
    0058
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #116: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis

    The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Pediatrics
    • Preventive Medicine
    • Urgent Care
    ID:
    117
    NQF:
    0055
    eMeasure ID:
    CMS131v12
    High Priority:
    No

    2024 MIPS Measure #117: Diabetes: Eye Exam

    Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam during the measurement period or in the 12 months prior to the measurement period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Ophthalmology
    ID:
    126
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation

    Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    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:
    155
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #155: Falls: Plan of Care

    Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    176
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #176: Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy

    If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Dermatology
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    • Rheumatology
    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:
    236
    NQF:
    eMeasure ID:
    CMS165v12
    High Priority:
    Yes

    2024 MIPS Measure #236: Controlling High Blood Pressure

    Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (< 140/90mmHg) during the measurement period.

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Pulmonology
    • Rheumatology
    • Vascular Surgery
    ID:
    238
    NQF:
    0022
    eMeasure ID:
    CMS156v12
    High Priority:
    Yes

    2024 MIPS Measure #238: Use of High-Risk Medications in Older Adults

    Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Oncology/Hematology
    • Ophthalmology
    • Otolaryngology
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Urology
    ID:
    243
    NQF:
    0643
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting

    Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.

    Definition:

    Referral - A “referral” is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).

    NOTE: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months. In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Preventive Medicine
    ID:
    277
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #277: Sleep Apnea: Severity Assessment at Initial Diagnosis

    Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea.

    Measure Type
    • Process
    Specifications
    Specialty
    • Internal Medicine
    • Neurology
    • Otolaryngology
    • Pulmonology
    ID:
    279
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

    Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available)

    Measure Type
    • Process
    Specifications
    Specialty
    • Internal Medicine
    • Neurology
    • Otolaryngology
    • Pulmonology
    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:
    309
    NQF:
    eMeasure ID:
    CMS124v12
    High Priority:
    No

    2024 MIPS Measure #309: Cervical Cancer Screening

    Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
    - Women age 21-64 who had cervical cytology performed within the last 3 years
    - Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:
    318
    NQF:
    0101
    eMeasure ID:
    CMS139v12
    High Priority:
    Yes

    2024 MIPS Measure #318: Falls: Screening for Future Fall Risk

    Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Nephrology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Therapy/Occupational Therapy
    • Podiatry
    ID:
    326
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

    Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Skilled Nursing Facility
    ID:
    331
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

    Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:
    332
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

    Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:
    338
    NQF:
    2082
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #338: HIV Viral Load Suppression

    Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period, with an eligible encounter in the first 240 days of the performance period, whose last HIV viral load test result was less than 200 copies/mL during the performance period.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    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:
    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:
    377
    NQF:
    eMeasure ID:
    CMS90v13
    High Priority:
    Yes

    2024 MIPS Measure #377: Functional Status Assessments for Heart Failure

    Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    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:
    387
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #387: Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

    Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    ID:
    398
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #398: Optimal Asthma Control

    Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Pulmonology
    ID:
    400
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #400: One-Time Screening for Hepatitis C Virus (HCV) for all Patients

    Percentage of patients aged ≥ 18 years who have never been tested for Hepatitis C Virus (HCV) infection who receive an HCV infection test AND who have treatment initiated within three months or who are referred to a clinician who treats HCV infection within one month if tested positive for HCV.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Nephrology
    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:
    418
    NQF:
    0053
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #418: Osteoporosis Management in Women Who Had a Fracture

    The percentage of women 50-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    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:
    438
    NQF:
    eMeasure ID:
    CMS347v7
    High Priority:
    No

    2024 MIPS Measure #438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

    Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the performance period:

    • All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
    • Patients aged 20 to 75 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
    • Patients aged 40 to 75 years with a diagnosis of diabetes; OR
    • Patients aged 40 to 75 with a 10-year ASCVD risk score of ≥ 20 percent.
    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Preventive Medicine
    ID:
    441
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

    The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:

    • Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND
    • Most recent tobacco status is Tobacco Free -- AND
    • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND
    • Statin Use Unless Contraindicated
    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Vascular Surgery
    ID:
    443
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #443: Non-Recommended Cervical Cancer Screening in Adolescent Females

    The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:
    468
    NQF:
    3175
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #468: Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

    Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Physical Medicine
    ID:
    472
    NQF:
    3475e
    eMeasure ID:
    CMS249v6
    High Priority:
    Yes

    2024 MIPS Measure #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

    Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:
    475
    NQF:
    eMeasure ID:
    CMS349v6
    High Priority:
    No

    2024 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
    Specifications
    Specialty
    • Certified Nurse Midwife
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    ID:
    476
    NQF:
    eMeasure ID:
    CMS771v5
    High Priority:
    Yes

    2024 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

    Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Urology
    ID:
    483
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #483: Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)

    The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patientreported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    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:
    488
    NQF:
    eMeasure ID:
    CMS951v2
    High Priority:
    No

    2024 MIPS Measure #488: Kidney Health Evaluation

    Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Nephrology
    • Preventive Medicine
    • Urology
    ID:
    493
    NQF:
    3620
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #493: Adult Immunization Status

    Percentage of patients 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; and pneumococcal.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Otolaryngology
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    495
    NQF:
    3665
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #495: Ambulatory Palliative Care Patients' Experience of Feeling Heard and Understood

    The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Oncology/Hematology
    ID:
    497
    NQF:
    3665
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #497: Preventive Care and Wellness (Composite)

    Percentage of patients who received age- and sex-appropriate preventive screenings and wellness services. This measure is a composite of seven component measures that are based on recommendations for preventive care by the U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), American Association of Clinical Endocrinology (AACE), and American College of Endocrinology (ACE)

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    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:
    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
    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
     
  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 are suggestions for your specialty:

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