MVP ID: M1420
Most applicable medical specialty(s):
Ophthalmology, Optometry
The Complete Ophthalmologic Care MVP assesses meaningful outcomes in cataract, glaucoma, retinal detachment, and broadly applicable ocular care.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 012 - Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
- Quality ID: 019 - Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
- Quality ID: 117 - Diabetes: Eye Exam
- Quality ID: 130 - Documentation of Current Medications in the Medical Record
- Quality ID: 141 - Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care.
- Quality ID: 191 - Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
- Quality ID: 226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Quality ID: 303 - Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
- Quality ID: 304 - Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
- Quality ID: 374 - Closing the Referral Loop: Receipt of Specialist Report
- Quality ID: 384 - Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
- Quality ID: 385 - Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
- Quality ID: 389 - Cataract Surgery: Difference Between Planned and Final Refraction
- Quality ID: 487 - Screening for Social Drivers of Health
- Quality ID: 499 - Appropriate screening and plan of care for elevated intraocular pressure following intravitreal or periocular steroid therapy
- Quality ID: 500 - Acute posterior vitreous detachment appropriate examination and follow-up
- Quality ID: 501 - Acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow-up
- Quality ID: 503 - Gains in Patient Activation Measure (PAM) Scores at 12 Months
- Quality ID: IRIS2 - Glaucoma – Intraocular Pressure Reduction
- Quality ID: IRIS13 - Diabetic Macular Edema - Loss of Visual Acuity
- Quality ID: IRIS39 - Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure
- Quality ID: IRIS54 - Complications After Cataract Surgery
- Quality ID: IRIS58 - Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days
- Quality ID: IRIS61 - Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery
Improvement Activities
Report one improvement activity from the list below:
- IA_AHE_1: Enhance Engagement of Medicaid and Other Underserved Populations
- IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
- IA_BE_4: Engagement of patients through implementation of improvements in patient portal
- IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings
- IA_BE_25: Drug Cost Transparency
- IA_CC_9: Implementation of practices/processes for developing regular individual care plans
- IA_CC_10: are transition documentation practice improvements
- IA_CC_13: Practice Improvements to Align with OpenNotes Principles
- IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_13: Chronic Care and Preventative Care Management for Empaneled Patients
- IA_PM_16: Implementation of medication management practice improvements
- IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
Cost
Calculated by CMS using administrative claims data:
Population Health Measures
CMS will calculate both population health measures using administrative claims data (if case minimum requirements are met) and assign the higher of these measures to the Quality score. If neither of the population health measures can be calculated, they will be excluded from scoring.
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Actions to Limit or Restrict Compatibility or Interoperability of CEHRT Attestation
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange OR
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review Attestation
MVP Registration
- MVP Participants must register between April 1 – December 1, 2025 to report an MVP in 2025.
- To register, MVP Participants must select:
- The MVP they intend to report.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- Whether they plan to administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey, if it’s a quality measure option in the selected MVP.
- The participation option they plan to use: individual, group, subgroup, or APM Entity.
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 1, 2025).
- Report on an MVP they didn’t register for during the 2025 performance year.
- Report on more than one MVP.