MVP ID: M1422
Most applicable medical specialty(s):
Gastroenterology, Nonphysician Practitioners, Nurse Practitioner, Physician Assistants
The Gastroenterology Care MVP focuses on the clinical theme of providing treatment and management of the digestive system and the liver.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 113 - Colorectal Cancer Screening
- Quality ID: 130 - Documentation of Current Medications in the Medical Record
- Quality ID: 185 - Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use
- Quality ID: 226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Quality ID: 275 - Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
- Quality ID: 320 - Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
- Quality ID: 374 - Closing the Referral Loop: Receipt of Specialist Report
- Quality ID: 400 - One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation
- Quality ID: 401 - Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
- Quality ID: 487 - Screening for Social Drivers of Health
- Quality ID: 503 - Gains in Patient Activation Measure (PAM) Scores at 12 Months
- Quality ID: GIQIC23 - Appropriate follow-up interval based on pathology findings in screening colonoscopy
- Quality ID: GIQIC26 - Screening Colonoscopy Adenoma Detection Rate
- Quality ID: NHCR4 - Repeat screening or surveillance colonoscopy recommended within one year due to inadequate bowel preparation
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_AHE_3: Promote Use of Patient-Reported Outcome Tools
- IA_AHE_6: Provide Education Opportunities for New Clinicians
- 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_CC_7: Regular training in care coordination
- IA_CC_9: Implementation of practices/processes for developing regular individual care plans
- IA_CC_10: Care 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
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_SSC_1: Screening/Surveillance Colonoscopy
- Measure ID: TPCC_1: Total Per Capita Cost (TPCC)
Population Health Measures
Select one population health measure to be scored by CMS using administrative claims data:
- #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:
- Prevention of Information Blocking
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP) (Optional)
- 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
- 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
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.
- 1 population health measure included in the MVP.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- 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.