2024 MIPS Measures Relevant to Urology

  1. 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:
    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:
    102
    NQF:
    0389
    eMeasure ID:
    CMS129v13
    High Priority:
    Yes

    2024 MIPS Measure #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

    Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer.

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology/Hematology
    • Radiation Oncology
    • Urology
    ID:
    104
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #104: Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer

    Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate.

    Measure Type
    • Process
    Specifications
    Specialty
    • Urology
    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:
    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
    • 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:
    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:
    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:
    321
    NQF:
    0005
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #321: CAHPS for MIPS Clinician/Group Survey

    The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows:                                                   •

    • Getting timely care, appointments, and information (Not endorsed by NQF);
    • How well providers Communicate (Not endorsed by NQF);
    • Patient’s Rating of Provider (NQF endorsed #0005);
    • Access to Specialists (Not endorsed by NQF);
    • Health Promotion & Education (Not endorsed by NQF);
    • Shared Decision Making (Not endorsed by NQF);
    • Health Status/Functional Status (Not endorsed by NQF);
    • Courteous and Helpful Office Staff (NQF endorsed #0005);
    • Care Coordination (Not endorsed by NQF); and
    • Stewardship of Patient Resources (Not endorsed by NQF).
    Measure Type
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Oncology/Hematology
    • Urology
    ID:
    358
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #358: Patient-Centered Surgical Risk Assessment and Communication

    Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Podiatry
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    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:
    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:
    432
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

    Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:
    433
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

    Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:
    453
    NQF:
    0210
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #453: Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)

    Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology/Hematology
    • Urology
    ID:
    457
    NQF:
    0216
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #457: Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)

    Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Oncology/Hematology
    • Urology
    ID:
    462
    NQF:
    eMeasure ID:
    CMS645v7
    High Priority:
    No

    2024 MIPS Measure #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

    Percentage of patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Oncology/Hematology
    • Urology
    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:
    481
    NQF:
    eMeasure ID:
    CMS646v4
    High Priority:
    Yes

    2024 MIPS Measure #481: Intravesical Bacillus-Calmette-Guerin for Non-muscle Invasive Bladder Cancer

    Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging

    Measure Type
    • Process
    Specifications
    Specialty
    • 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:
    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:
    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
     
  2. PI: Promoting Interoperability - 25% of total score: For a minimum of 180 days, report all required measures. EHR technology certified to the 2015 Cures Update 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.
  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. Suggestions that might be applicable to your specialty include:

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