MVP ID: M1423
Most applicable medical specialty(s):
Urology, General Urologists, Urology Oncologists, Urology Care for Women, Nonphysician Practitioners, Nurse Practitioners, Physician Assistants
The Optimal Care for Patients with Urologic Conditions MVP focuses on assessing optimal care for patients treated for a broad range of urologic conditions, including kidney stones, urinary incontinence, bladder cancer, and prostate cancer.
Quality
- Quality ID: 050 - Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
- Quality ID: 318 - Falls: Screening for Future Fall Risk
- Quality ID: 321 - CAHPS for MIPS Clinician/Group Survey
- Quality ID: 358 - Patient-Centered Surgical Risk Assessment and Communication
- Quality ID: 462 - Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
- Quality ID: 476 - Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
- Quality ID: 481 - Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer
- Quality ID: 487 - Screening for Social Drivers of Health
- Quality ID: 503 - Gains in Patient Activation Measure (PAM) Scores at 12 Months
- Quality ID: AQUA8 - Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy
- Quality ID: AQUA14 - Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment
- Quality ID: AQUA15 - Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures
- Quality ID: AQUA16 - Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease
- Quality ID: MUSIC4 - Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_AHE_3: Promote Use of Patient-Reported Outcome Tools - High
- IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
- IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings - High
- IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care - Medium
- IA_CC_7: Regular training in care coordination
- IA_CC_13: Practice Improvements to Align with OpenNotes Principles - Medium
- IA_CC_17: Patient Navigator Program
- IA_EPA_2: Use of telehealth services that expand practice access
- IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways - High
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_17: Participation in Population Health Research
- IA_PM_21: Advance Care Planning
- IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
- IA_PSPA_12: Participation in private payer CPIA
- IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
- IA_PSPA_21: Implementation of fall screening and assessment programs
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_RUSST_1 Renal or Ureteral Stone Surgical Treatment
- Measure ID: MSPB_1 Medicare Spending Per Beneficiary (MSPB) Clinician
- Measure ID: COST_PC_1 Prostate Cancer episode-based cost measure
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.